Chapter01

CHAPTER 1:
Staffing

1.1 Child:Staff Ratio, Group Size, and Minimum Age

1.1.1 Child:Staff Ratio and Group Size

STANDARD 1.1.1.1: Ratios for Small Family Child Care Homes

The small family child care home caregiver/teacher child:staff ratios should conform to the following table:

If the small family child care home caregiver/teacher has no children under two years of age in care,	then the small family child care home caregiver/teacher may have one to six children over two years of age in care
If the small family child care home caregiver/teacher has one child under two years of age in care,	then the small family child care home caregiver/teacher may have one to three children over two years of age in care
If the small family child care home caregiver/teacher has two children under two years of age in care,	then the small family child care home caregiver/teacher may have no children over two years of age in care

The small family child care home caregiver’s/teacher’s own children as well as any other children in the home temporarily requiring supervision should be included in the child:staff ratio. During nap time, at least one adult should be physically present in the same room as the children.

RATIONALE: Low child:staff ratios are most critical for infants and toddlers (birth to thirty-six months) (1). Infant and child development and caregiving quality improves when group size and child:staff ratios are smaller (2). Improved verbal interactions are correlated with lower child:staff ratios (3). Small ratios are very important for young children’s development (7). The recommended group size and child:staff ratio allow three- to five-year-old children to have continuing adult support and guidance while encouraging independent, self-initiated play and other activities (4).

The National Fire Protection Association (NFPA) requires in the NFPA 101: Life Safety Code that small family child care homes serve no more than two clients incapable of self-preservation (5).

Direct, warm social interaction between adults and children is more common and more likely with lower child:staff ratios. Caregivers/teachers must be recognized as performing a job for groups of children that parents/guardians of twins, triplets, or quadruplets would rarely be left to handle alone. In child care, these children do not come from the same family and must learn a set of common rules that may differ from expectations in their own homes (6,8).

COMMENTS: It is best practice for the caregiver/teacher to remain in the same room as the infants when they are sleeping to provide constant supervision. However in small family child care programs, this may be difficult in practice because the caregiver/teacher is typically alone, and all of the children most likely will not sleep at the same time. In order to provide constant supervision during sleep, caregivers/teachers could consider discontinuing the practice of placing infant(s) in a separate room for sleep, but instead placing the infant’s crib in the area used by the other children so the caregiver/teacher is able to supervise the sleeping infant(s) while caring for the other children. Care must be taken so that placement of cribs in an area used by other children does not encroach upon the minimum usable floor space requirements. Infants do not require a dark and quiet place for sleep. Once they become accustomed, infants are able to sleep without problems in environments with light and noise. By placing infants (as well as all children in care) on the main (ground) level of the home for sleep and remaining on the same level as the children, the caregiver/teacher is more likely able to evacuate the children in less time; thus, increasing the odds of a successful evacuation in the event of a fire or another emergency. Caregivers/teachers must also continually monitor other children in this area so they are not climbing on or into the cribs. If the caregiver/teacher cannot remain in the same room as the infant(s) when the infant is sleeping, it is recommended that the caregiver/teacher should do visual checks every ten to fifteen minutes to make sure the infant’s head is uncovered, and assess the infant’s breathing, color, etc. Supervision is recommended for toddlers and preschoolers to ensure safety and prevent behaviors such as inappropriate touching or hurting other sleeping children from taking place. These behaviors may go undetected if a caregiver/teacher is not present. If caregiver/teacher is not able to remain in the same room as the children, frequent visual checks are also recommended for toddlers and preschoolers when they are sleeping.

Each state has its own set of regulations that specify child:staff ratios. To view a particular state’s regulations, go to the National Resource Center for Health and Safety in Child Care and Early Education’s (NRC) Website: http://nrckids.org. Some states are setting limits on the number of school-age children that are allowed to be cared for in small family child care homes, e.g., two school-age children in addition to the maximum number allowed for infants/preschool children. No data are available to support using a different ratio where school-age children are in family child care homes. Since school-age children require focused caregiver/teacher time and attention for supervision and adult-child interaction, this standard applies the same ratio to all children three-years-old and over. The family child care caregiver/teacher must be able to have a positive relationship and provide guidance for each child in care. This standard is consistent with ratio requirements for toddlers in centers as described in Standard 1.1.1.2.

Unscheduled inspections encourage compliance with this standard.

TYPE OF FACILITY: Small Family Child Care Home

REFERENCES:

1. Zero to Three. 2007. The infant-toddler set-aside of the Child Care and Development Block Grant: Improving quality child care for infants and toddlers. Washington, DC: Zero to Three. http://main
.zerotothree.org/site/DocServer/Jan_07_Child_Care_Fact
_Sheet.pdf.

2. National Institute of Child Health and Human Development (NICHD). 2006. The NICHD study of early child care and youth development: Findings for children up to age 4 1/2 years. Rockville, MD: NICHD. http://www.nichd.nih.gov/publications/pubs/upload/seccyd_051206.pdf.

3. Goldstein, A., K. Hamm, R. Schumacher. Supporting growth and development of babies in child care: What does the research say? Washington, DC: Center for Law and Social Policy (CLASP); Zero to Three. http://main.zerotothree.org/site/DocServer/ChildCareResearchBrief.pdf.

4. De Schipper, E. J., J. M. Riksen-Walraven, S. A. E. Geurts. 2006. Effects of child-caregiver ratio on the interactions between caregivers and children in child-care centers: An experimental study. Child Devel 77:861-74.

5. National Fire Protection Association (NFPA). 2009. NFPA 101: Life safety code. 2009 ed. Quincy, MA: NFPA.

6. Fiene, R. 2002. 13 indicators of quality child care: Research update. Washington, DC: U.S. Department of Health and Human Services, Office of the Assistant Secretary for Planning and Evaluation. http://aspe.hhs.gov/hsp/ccquality-ind02/.

7. Zigler, E., W. S. Gilliam, S. M. Jones. 2006. A vision for universal preschool education, 107-29. New York: Cambridge University Press.

8. Stebbins, H. 2007. State policies to improve the odds for the healthy development and school readiness of infants and toddlers. Washington, DC: Zero to Three. http://main.zerotothree.org/site/DocServer/NCCP_article_for_BM_final.pdf.

STANDARD 1.1.1.2: Ratios for Large Family Child Care Homes and Centers

Child:staff ratios in large family child care homes and centers should be maintained as follows during all hours of operation, including in vehicles during transport.

Large Family Child Care Homes

Age	Maximum Child:Staff Ratio	Maximum Group Size

≤ 12 months	2:1	6
13-23 months	2:1	8
24-35 months	3:1	12
3-year-olds	7:1	12
4- to 5-year-olds	8:1	12
6- to 8-year-olds	10:1	12
9- to 12-year-olds	12:1	12

During nap time for children birth through thirty months of age, the child:staff ratio must be maintained at all times regardless of how many infants are sleeping. They must also be maintained even during the adult’s break time so that ratios are not relaxed.

Child Care Centers

Age	Maximum Child:Staff Ratio	Maximum Group Size

≤ 12 months	3:1	6
13-35 months	4:1	8
3-year-olds	7:1	14
4-year-olds	8:1	16
5-year-olds	8:1	16
6- to 8-year-olds	10:1	20
9- to 12-year-olds	12:1	24

During nap time for children ages thirty-one months and older, at least one adult should be physically present in the same room as the children and maximum group size must be maintained. Children over thirty-one months of age can usually be organized to nap on a schedule, but infants and toddlers as individuals are more likely to nap on different schedules. In the event even one child is not sleeping the child should be moved to another activity where appropriate supervision is provided.

If there is an emergency during nap time other adults should be on the same floor and should immediately assist the staff supervising sleeping children. The caregiver/teacher who is in the same room with the children should be able to summon these adults without leaving the children.

When there are mixed age groups in the same room, the child:staff ratio and group size should be consistent with the age of most of the children. When infants or toddlers are in the mixed age group, the child:staff ratio and group size for infants and toddlers should be maintained. In large family child care homes with two or more caregivers/teachers caring for no more than twelve children, no more than three children younger than two years of age should be in care.

Children with special health care needs or who require more attention due to certain disabilities may require additional staff on-site, depending on their special needs and the extent of their disabilities (1). See Standard 1.1.1.3.

At least one adult who has satisfactorily completed a course in pediatric first aid, including CPR skills within the past three years, should be part of the ratio at all times.

RATIONALE: These child:staff ratios are within the range of recommendations for each age group that the National Association for the Education of Young Children (NAEYC) uses in its accreditation program (5). The NAEYC recommends a range that assumes the director and staff members are highly trained and, by virtue of the accreditation process, have formed a staffing pattern that enables effective staff functioning. The standard for child:staff ratios in this document uses a single desired ratio, rather than a range, for each age group. These ratios are more likely than less stringent ratios to support quality experiences for young children.

Low child:staff ratios for non-ambulatory children are essential for fire safety. The National Fire Protection Association (NFPA), in its NFPA 101: Life Safety Code, recommends that no more than three children younger than two years of age be cared for in large family child care homes where two staff members are caring for up to twelve children (6).

Children benefit from social interactions with peers. However, larger groups are generally associated with less positive interactions and developmental outcomes. Group size and ratio of children to adults are limited to allow for one to one interaction, intimate knowledge of individual children, and consistent caregiving (7).

Studies have found that children (particularly infants and toddlers) in groups that comply with the recommended ratio receive more sensitive and appropriate caregiving and score higher on developmental assessments, particularly vocabulary (1,9).

As is true in small family child care homes, Standard 1.1.1.1, child:staff ratios alone do not predict the quality of care. Direct, warm social interaction between adults and children is more common and more likely with lower child:staff ratios. Caregivers/teachers must be recognized as performing a job for groups of children that parents/guardians of twins, triplets, or quadruplets would rarely be left to handle alone. In child care, these children do not come from the same family and must learn a set of common rules that may differ from expectations in their own homes (10).

Similarly, low child:staff ratios are most critical for infants and young toddlers (birth to twenty-four months) (1). Infant development and caregiving quality improves when group size and child:staff ratios are smaller (2). Improved verbal interactions are correlated with lower ratios (3). For three- and four-year-old children, the size of the group is even more important than ratios. The recommended group size and child:staff ratio allow three- to five-year-old children to have continuing adult support and guidance while encouraging independent, self-initiated play and other activities (4).

In addition, the children’s physical safety and sanitation routines require a staff that is not fragmented by excessive demands. Child:staff ratios in child care settings should be sufficiently low to keep staff stress below levels that might result in anger with children. Caring for too many young children, in particular, increases the possibility of stress to the caregiver/teacher, and may result in loss of the caregiver’s/teacher’s self-control (11).

Although observation of sleeping children does not require the physical presence of more than one caregiver/teacher for sleeping children thirty-one months and older, the staff needed for an emergency response or evacuation of the children must remain available on site for this purpose. Ratios are required to be maintained for children thirty months and younger during nap time due to the need for closer observation and the frequent need to interact with younger children during periods while they are resting. Close proximity of staff to these younger groups enables more rapid response to situations where young children require more assistance than older children, e.g., for evacuation. The requirement that a caregiver/teacher should remain in the sleeping area of children thirty-one months and older is not only to ensure safety, but also to prevent inappropriate behavior from taking place that may go undetected if a caregiver/teacher is not present. While nap time may be the best option for regular staff conferences, staff lunch breaks, and staff training, one staff person should stay in the nap room, and the above staff activities should take place in an area next to the nap room so other staff can assist if emergency evacuation becomes necessary. If a child with a potentially life-threatening special health care need is present, a staff member trained in CPR and pediatric first aid and one trained in administration of any potentially required medication should be available at all times.

COMMENTS: The child:staff ratio indicates the maximum number of children permitted per caregiver/teacher (8). These ratios assume that caregivers/teachers do not have time-consuming bookkeeping and housekeeping duties, so they are free to provide direct care for children. The ratios do not include other personnel (such as bus drivers) necessary for specialized functions (such as driving a vehicle).

Group size is the number of children assigned to a caregiver/teacher or team of caregivers/teachers occupying an individual classroom or well-defined space within a larger room (8). The “group” in child care represents the “home room” for school-age children. It is the psychological base with which the school-aged child identifies and from which the child gains continual guidance and support in various activities. This standard does not prohibit larger numbers of school-aged children from joining in occasional collective activities as long as child:staff ratios and the concept of “home room” are maintained.

Unscheduled inspections encourage compliance with this standard.

These standards are based on what children need for quality nurturing care. Those who question whether these ratios are affordable must consider that efforts to limit costs can result in overlooking the basic needs of children and creating a highly stressful work environment for caregivers/teachers. Community resources, in addition to parent/guardian fees and a greater public investment in child care, can make critical contributions to the achievement of the child:staff ratios and group sizes specified in this standard. Each state has its own set of regulations that specify child:staff ratios. To view a particular state’s regulations, go to the National Resource Center for Health and Safety in Child Care and Early Education’s (NRC) Website: http://nrckids.org.

TYPE OF FACILITY: Center; Large Family Child Care Home

REFERENCES:

5. National Association for the Education of Young Children (NAEYC). 2007. Early childhood program standards and accreditation criteria. Washington, DC: NAEYC.

6. National Fire Protection Association (NFPA). 2009. NFPA 101: Life safety code. 2009 ed. Quincy, MA: NFPA.

7. Bradley, R. H., D. L. Vandell. 2007. Child care and the well-being of children. Arch Ped Adolescent Med 161:669-76.

8. Murph, J. R., S. D. Palmer, D. Glassy, eds. 2005. Health in child care: A manual for health professionals. 4th ed. Elk Grove Village, IL: American Academy of Pediatrics.

9. Vandell, D. L., B. Wolfe. 2000. Child care quality: Does it matter and does it need to be improved? Washington, DC: U.S. Department of Health and Human Services. http://aspe.hhs.gov/hsp/ccquality00/.

10. Fiene, R. 2002. 13 indicators of quality child care: Research update. Washington, DC: U.S. Department of Health and Human Services, Office of the Assistant Secretary for Planning and Evaluation. http://aspe.hhs.gov/hsp/ccquality-ind02/.

11. Wrigley, J., J. Derby. 2005. Fatalities and the organization of child care in the United States. Am Socio Rev 70:729-57.

STANDARD 1.1.1.3: Ratios for Facilities Serving Children with Special Health Care Needs and Disabilities

Facilities enrolling children with special health care needs and disabilities should determine, by an individual assessment of each child’s needs, whether the facility requires a lower child:staff ratio.

RATIONALE: The child:staff ratio must allow the needs of the children enrolled to be met. The facility should have sufficient direct care professional staff to provide the required programs and services. Integrated facilities with fewer resources may be able to serve children who need fewer services, and the staffing levels may vary accordingly. Adjustment of the ratio allows for the flexibility needed to meet each child’s type and degree of special need and encourage each child to participate comfortably in program activities. Adjustment of the ratio produces flexibility without resulting in a need for care that is greater than the staff can provide without compromising the health and safety of other children. The facility should seek consultation with parents/guardians, a child care health consultant (CCHC), and other professionals, regarding the appropriate child:staff ratio. The facility may wish to increase the number of staff members if the child requires significant special assistance (1).

COMMENTS: These ratios do not include personnel who have other duties that might preclude their involvement in needed supervision while they are performing those duties, such as therapists, cooks, maintenance workers, or bus drivers.

TYPE OF FACILITY: Center; Large Family Child Care Home; Small Family Child Care Home

REFERENCES:

1. University of North Carolina at Chapel Hill, FPG Child Development Institute. The national early childhood technical assistance center. http://www.nectac.org.

STANDARD 1.1.1.4: Ratios and Supervision During Transportation

Child:staff ratios established for out-of-home child care should be maintained on all transportation the facility provides or arranges. Drivers should not be included in the ratio. No child of any age should be left unattended in or around a vehicle, when children are in a car, or when they are in a car seat. A face-to-name count of children should be conducted prior to leaving for a destination, when the destination is reached, before departing for return to the facility and upon return. Caregivers/teachers should also remember to take into account in this head count if any children were picked up or dropped off while being transported away from the facility.

RATIONALE: Children must receive direct supervision when they are being transported, in loading zones, and when they get in and out of vehicles. Drivers must be able to focus entirely on driving tasks, leaving the supervision of children to other adults. This is especially important with young children who will be sitting in close proximity to one another in the vehicle and may need care during the trip. In any vehicle making multiple stops to pick up or drop off children, this also permits one adult to get one child out and take that child to a home, while the other adult supervises the children remaining in the vehicle, who would otherwise be unattended for that time (1). Children require supervision at all times, even when buckled in seat restraints. A head count is essential to ensure that no child is inadvertently left behind in or out of the vehicle. Child deaths in child care have occurred when children were mistakenly left in vehicles, thinking the vehicle was empty.

TYPE OF FACILITY: Center; Large Family Child Care Home

REFERENCES:

1. Aird, L. D. 2007. Moving kids safely in child care: A refresher course. Child Care Exchange (January/February): 25-28. http://www.childcareexchange.com/library/5017325.pdf.

STANDARD 1.1.1.5: Ratios and Supervision for Swimming, Wading, and Water Play

The following child:staff ratios should apply while children are swimming, wading, or engaged in water play:

Developmental Levels	Child:Staff Ratio
Infants	1:1
Toddlers	1:1
Preschoolers	4:1
School-age Children	6:1

Constant and active supervision should be maintained when any child is in or around water (4). During any swimming/wading/water play activities where either an infant or a toddler is present, the ratio should always be one adult to one infant/toddler. The required ratio of adults to older children should be met without including the adults who are required for supervision of infants and/or toddlers. An adult should remain in direct physical contact with an infant at all times during swimming or water play (4). Whenever children thirteen months and up to five years of age are in or around water, the supervising adult should be within an arm’s length providing “touch supervision” (6). The attention of an adult who is supervising children of any age should be focused on the child, and the adult should never be engaged in other distracting activities (4), such as talking on the telephone, socializing, or tending to chores.

A lifeguard should not be counted in the child:staff ratio.

RATIONALE: The circumstances surrounding drownings and water-related injuries of young children suggest that staffing requirements and environmental modifications may reduce the risk of this type of injury. Essential elements are close continuous supervision (1,4), four-sided fencing and self-locking gates around all swimming pools, hot tubs, and spas, and special safety covers on pools when they are not in use (2,7). Five-gallon buckets should not be used for water play (4). Water play using small (one quart) plastic pitchers and plastic containers for pouring water and plastic dish pans or bowls allow children to practice pouring skills. Between 2003 and 2005, a study of drowning deaths of children younger than five years of age attributed the highest percentage of drowning reports to an adult losing contact or knowledge of the whereabouts of the child (5). During the time of lost contact, the child managed to gain access to the pool (3).

COMMENTS: Water play includes wading. Touch supervision means keeping swimming children within arm’s reach and in sight at all times. Drowning is a “silent killer” and children may slip into the water silently without any splashing or screaming.

Ratios for supervision of swimming, wading and water play do not include personnel who have other duties that might preclude their involvement in supervision during swimming/wading/water play activities while they are performing those duties. This ratio excludes cooks, maintenance workers, or lifeguards from being counted in the child:staff ratio if they are involved in specialized duties at the same time. Proper ratios during swimming activities with infants are important. Infant swimming programs have led to water intoxication and seizures because infants may swallow excessive water when they are engaged in any submersion activities (1).

TYPE OF FACILITY: Center; Large Family Child Care Home; Small Family Child Care Home

REFERENCES:

1. American Academy of Pediatrics, Committee on Injury, Violence, and Poison Prevention. 2010. Policy statement: Prevention of drowning. Pediatrics 126:178-85.

2. U.S. Consumer Product Safety Commission (CPSC). Pool and spa safety: The Virginia Graeme Baker pool and spa safety act. http://www.poolsafely.gov/wp-content/uploads/VGBA.pdf.

3. Gipson, K. 2008. Pool and spa submersion: Estimated injuries and reported fatalities, 2008 report. Bethesda, MD: U.S. Consumer Product Safety Commission. http://www.cpsc.gov/LIBRARY/poolsub2008.pdf.

4. U.S. Consumer Product Safety Commission (CPSC). 2009. CPSC warns of in-home drowning dangers with bathtubs, bath seats, buckets. Release #10-008. http://www.cpsc.gov/cpscpub/prerel/prhtml10/10008.html.

5. Gipson, K. 2008. Submersions related to non-pool and non-spa products, 2008 report. Washington, DC: U.S. Consumer Product Safety Commission. http://www.cpsc.gov/library/FOIA/FOIA09/OS/nonpoolsub2008.pdf.

6. American Academy of Pediatrics, Committee on Injury, Violence, and Poison Prevention, J. Weiss. 2010. Technical report: Prevention of drowning. Pediatrics 126: e253-62.

7. Consumer Product Safety Commission. Steps for safety around the pool: The pool and spa safety act. Pool Safely. http://www
.poolsafely.gov/wp-content/uploads/360.pdf.

1.1.2 Minimum Age

STANDARD 1.1.2.1: Minimum Age to Enter Child Care

Reader’s Note: This standard reflects a desirable goal when sufficient resources are available; it is understood that for some families, waiting until three months of age to enter their infant in child care may not be possible.

Healthy full-term infants can be enrolled in child care settings as early as three months of age. Premature infants or those with chronic health conditions should be evaluated by their primary care providers and developmental specialists to make an individual determination concerning the appropriate age for child care enrollment.

RATIONALE: Brain anatomy, chemistry, and physiology undergo rapid development over the first ten to twelve weeks of life (1-6). Concurrently, and as a direct consequence of these shifts in central nervous system structure and function, infants demonstrate significant growth, irregularity, and eventually, organization of their behavior, physiology, and social responsiveness (1-3,5). Arousal responses to stimulation mature before the ability to self-regulate and control such responses in the first six to eight weeks of life causing infants to demonstrate an expanding range and fluctuation of behavioral state changes from quiet to alert to irritable (1-3,6). Infant behavior is most disorganized, most difficult to read and most frustrating to support at the six to eight week period (2,3). At approximately eight to twelve weeks after birth, full term infants typically undergo changes in brain function and behavior that helps caregivers/teachers understand and respond effectively to infants’ increasingly stable sleep-wake states, attention, self-calming efforts, feeding patterns and patterns of social engagement. Over the course of the third month, infants demonstrate an emerging capacity to sustain states of sleep and alert attention.

Infants, birth to three months of age, can become seriously ill very quickly without obvious signs (7). This increased risk to infants, birth to three months makes it important to minimize their exposure to children and adults outside their family, including exposures in child care (8). In addition, infants of mothers who return to work, particularly full-time, before twelve weeks of age, and are placed in group care may be at even greater risk for developing serious infectious diseases. These infants are less likely to receive recommended well-child care and immunizations and to be breastfed or are likely to have a shorter duration of breastfeeding (16,22).

Researchers report that breastfeeding duration was significantly higher in women with longer maternity leaves as compared to those with less than nine to twelve weeks leave (9,22). A leave of less than six weeks was associated with a much higher likelihood of stopping breastfeeding (10,22). Continuing breastfeeding after returning to work may be particularly difficult for lower income women who may have fewer support systems (11).

It takes women who have given birth about six weeks to return to the physical health they had prior to pregnancy (12). A significant portion of women reported child birth related symptoms five weeks after delivery (17). In contrast, women’s general mental health, vitality, and role function were improved with maternity leaves at twelve weeks or longer (13).

Birth of a child or adoption of a newborn, especially the first, requires significant transition in the family. First time parents/guardians are learning a new role and even with subsequent children, integration of the new family member requires several weeks of adaptation. Families need time to adjust physically and emotionally to the intense needs of a newborn (14,15).

COMMENTS: In an analysis of twenty-one wealthy countries including Australia, New Zealand, Canada, United States, Japan, and several European countries, the U.S. ranked twentieth in terms of unpaid and paid parental leave available to two-parent families with the birth of their child (18,21). Although Switzerland ranked twenty-first with fourteen versus twenty-four weeks as compared to the U.S. for both parents/guardians, eleven weeks of leave are paid in Switzerland. In this study of twenty-one countries, only Australia and the U.S. do not provide for paid leave after the birth of a child (18).

Major social policies in the U.S. were established with the Social Security Act in 1935 at a time when the majority of women were not employed (19,20). The Family and Medical Leave Act (FMLA) of 1993, which allows twelve weeks of leave, established for the first time job protected maternity leave for qualifying employees (16,20). Despite the importance of FMLA, only about 60% of the women in the workforce are eligible for job protected maternity leave. FMLA does not provide paid leave, which may force many women to return to work sooner than preferred (18). FMLA is not transferable between parents/guardians. However, five U.S. states support five to six weeks of paid maternity leave and a few companies allow generous paid leaves for select employees (21).

In a nationally representative sample, 84% of women and 74% of men supported expansion of the FMLA; furthermore, 90% of women and 72% of men reported that employers and government should do more to support families (21).

Substantial evidence exists to strengthen social policies, specifically job protected paid leave for all families, for at least the first twelve weeks of life, in order to promote the health and development of children and families (22). Investing in families during an important life transition, the birth or adoption of a child, reflects a society’s values and may in fact contribute to a healthier and more productive work force.

TYPE OF FACILITY: Center; Large Family Child Care Home; Small Family Child Care Home

RELATED STANDARDS:

Standard 2.1.1.5: Helping Families Cope with Separation

REFERENCES:

1. Staehelin, K., P. C. Bertea, E. Z. Stutz. 2007. Length of maternity leave and health of mother and child–a review. Int J Public Health 52:202-9.

2. Guendelman, S., J. L. Kosc, M. Pearl, S. Graham, J. Goodman, M. Kharrazi. 2009. Juggling work and breastfeeding: Effects of maternity leave and occupational characteristics. Pediatrics 123: e38-e46.

3. Kimbro, R. T. 2006. On-the-job moms: Work and breastfeeding initiation and duration for a sample of low-income women. Maternal Child Health J 10:19-26.

4. Cunningham, F. G., F. F. Gont, K. J. Leveno, L. C. Gilstrap, J. C. Hauth, K. D. Wenstrom. 2005. Williams obstretrics. 21st ed. New York: McGraw Hill.

5. McGovern P., B. Dowd, D. Gjerdingen, I. Moscovice, L. Kochevar, W. Lohman. 1997. Time off work and the postpartum health of employed women. Medical Care 35:507-21.

6. Carter, B., M. McGoldrick, eds. 2005. The expanded family life cycle: Individual, family, and social perspectives. 3rd ed. New York: Allyn and Bacon Classics.

7. Ishimine, P. 2006. Fever without source in children 0-36 months. Pediatric Clinics North Am 53:167.

8. Harper, M. 2004. Update on the management of the febrile infant. Clin Pediatric Emerg Med 5:5-12.

9. Carey, W. B., A. C. Crocker, E. R. Elias, H. M. Feldman, W. L. Coleman. 2009. Developmental-behavioral pediatrics. 4th ed. Philadelphia: W. B. Saunders.

10. Parmelee, A. H. Jr, W. Weiner, H. Schultz. 1964. Infant sleep patterns: From birth to 16 weeks of age. J Pediatrics 65:576-82.

11. Brazelton, T. B. 1962. Crying in infancy. Pediatrics 29:579-88.

12. Huttenlocher, P. R., C. de Courten. 1987. The development of synapses in striate cortex of man. Human Neurobiology 6:1-9.

13. Anders, T. F. 1992. Sleeping through the night: A developmental perspective. Pediatrics 90:554-60.

14. Edelstein, S., J. Sharlin, S. Edelstein. 2008. Life cycle nutrition: An evidence-based approach. Boston: Jones and Bartlett.

15. Robertson, S. S. 1987. Human cyclic motility: Fetal-newborn continuities and newborn state differences. Devel Psychobiology 20:425-42.

16. Berger, L. M., J. Hill, J. Waldfogel. 2005. Maternity leave, early maternal employment and child health and development in the US. Economic J 115: F29-F47.

17. McGovern, P., B. Dowd, D. Gjerdingen, C. R. Gross, S. Kenney, L. Ukestad, D. McCaffrey, U. Lundberg. 2006. Postpartum health of employed mothers 5 weeks after childbirth. Annals Fam Med 4:159-67.

18. Ray, R., J. C. Gornick, J. Schmitt. 2009. Parental leave policies in 21 countries: Assessing generosity and gender equality. Rev. ed. Washington, DC: Center for Economic and Policy Research.

19. Social Security Act. 1935. 42 USC 7.

20. Family and Medical Leave Act. 1993. 29 USC 2601.

21. Lovell, V., E. O’Neill, S. Olsen. 2007. Maternity leave in the United States: Paid parental leave is still not standard, even among the best U.S. employers. Washington, DC: Institute for Women’s Policy Research. http://iwpr.org/pdf/parentalleaveA131.pdf.

22. Human Rights Watch. 2011. Failing its families: Lack of paid leave and work-family supports in the U.S. http://www.hrw.org/en/reports/2011/02/23/failing-its-families-0/.

1.2 Recruitment and Background Screening

STANDARD 1.2.0.1: Staff Recruitment

Staff recruitment should be based on a policy of non-discrimination with regard to gender, race, ethnicity, disability, or religion, as required by the Equal Employment Opportunity Act (EEOA). Centers should have a plan of action for recruiting and hiring a diverse staff that is representative of the children in the facility’s care and people in the community with whom the child is likely to have contact as a part of life experience. Staff recruitment policies should adhere to requirements of the Americans with Disabilities Act (ADA) as it applies to employment. The job description for each position should be clearly written, and the suitability of an applicant should be measured with regard to the applicant’s qualifications and abilities to perform the tasks required in the role.

RATIONALE: Child care businesses must adhere to federal law. In addition, child care businesses should model diversity and non-discrimination in their employment practices to enhance the quality of the program by supporting diversity and tolerance for individuals on the staff who are competent caregivers/teachers with different background and orientation in their private lives. Children need to see successful role models from their own ethnic and cultural groups and be able to develop the ability to relate to people who are different from themselves (1).

The goal of the ADA in employment is to reasonably accommodate applicants and employees with disabilities, to provide them equal employment opportunity and to integrate them into the program’s staff to the extent feasible, given the individual’s limitations. Under the ADA, employers are expected to make reasonable accommodations for persons with disabilities. Some disabilities may be accommodated, whereas others may not allow the person to do essential tasks. The fairest way to address this evaluation is to define the tasks and measure the abilities of applicants to perform them (2).

COMMENTS: In staff recruiting, the hiring pool should extend beyond the immediate neighborhood of the child’s residence or location of the facility, to reflect the diversity of the people with whom the child can be expected to have contact as a part of life experience.

Reasons to deny employment include the following:

The applicant or employee is not qualified or is unable to perform the essential functions of the job with or without reasonable accommodations;
Accommodation is unreasonable or will result in undue hardship to the program;
The applicant’s or employee’s condition will pose a significant threat to the health or safety of that individual or of other staff members or children.

Accommodations and undue hardship are based on each individual situation.

The U.S. Equal Employment Opportunity Commission (EEOC) does not enforce the protections that prohibit discrimination and harassment based on sexual orientation, status as a parent, marital status, or political affiliation. However, other federal agencies and many states and municipalities do. For assistance in locating your state or local agency’s rules go to http://www.eeoc.gov/field/ (3).

Caregivers/teachers can obtain copies of the EEOA and the ADA from their local public library. Facilities should consult with ADA experts through the U.S. Department of Education funded Disability and Business Technical Assistance Centers (DBTAC) throughout the country. These centers can be reached by calling 1-800-949-4232 (callers will be routed to the appropriate region), or by visiting http://www.adata
.org/Static/Home.aspx.

TYPE OF FACILITY: Center; Large Family Child Care Home; Small Family Child Care Home

REFERENCES:

1. Chang, H. 2006. Developing a skilled, ethnically and linguistically diverse early childhood workforce. Adapted from Getting ready for quality: The critical importance of developing and supporting a skilled, ethnically and linguistically diverse early childhood workforce. http://www.buildinitiative.org/files/DiverseWorkforce.pdf.

2. U.S. Department of Justice, Civil Rights Division, Disability Rights Section. 1997. Commonly asked questions about child care centers and the Americans with Disabilities Act. http://www.ada.gov/childq&a.htm.

3. U.S. Equal Employment Opportunity Commission. Discrimination based on sexual orientation, status as a parent, marital status and political affiliation. http://www.eeoc.gov/federal/otherprotections.cfm.

STANDARD 1.2.0.2: Background Screening

Directors of centers and caregivers/teachers in large and small family child care homes should conduct a complete background screening before employing any staff member (including substitutes, cooks, clerical staff, transportation staff, bus drivers, or custodians who will be on the premises or in vehicles when children are present). The background screening should include:

Name and address verification;
Social Security number verification;
Education verification;
Employment history;
Alias search;
Driving history through state Department of Motor Vehicles records;
Background screening of:
1. State and national criminal history records;
2. Child abuse and neglect registries;
3. Licensing history with any other state agencies (i.e., foster care, mental health, nursing homes, etc.);
4. Fingerprints; and
5. Sex offender registries;
Court records;
References.

All family members over age ten living in large and small family child care homes should also have background screenings.

Drug tests may also be incorporated into the background screening. Written permission to obtain the background screening (with or without a drug screen) should be obtained from the prospective employee. Consent to the background investigation should be required for employment consideration.

When checking references and when conducting employee or volunteer interviews, prospective employers should specifically ask about previous convictions and arrests, investigation findings, or court cases with child abuse/neglect or child sexual abuse. Failure of the prospective employee to disclose previous history of child abuse/neglect or child sexual abuse is grounds for immediate dismissal.

Persons should not be hired or allowed to work or volunteer in the child care facility if they acknowledge being sexually attracted to children or having physically or sexually abused children, or are known to have committed such acts.

Background screenings should be repeated periodically taking into consideration state laws and/or requirements. Screenings should be repeated more frequently if there are additional concerns.

RATIONALE: To ensure their safety and physical and mental health, children should be protected from any risk of abuse or neglect. Although few persons will acknowledge past child abuse or neglect to another person, the obvious attention directed to the question by the licensing agency or caregiver/teacher may discourage some potentially abusive individuals from seeking employment in child care. Performing diligent background screenings also protects the child care facility against future legal challenges (1). Having a state credentialing system can reduce the time required to ensure all those caring for children have had the required background screening review.

COMMENTS: Directors who are conducting screenings and caregivers/teachers who are asked to submit a background screening record should contact their state child care licensing agency for the appropriate documentation required. Fingerprinting can be secured at local law enforcement offices or the State Bureau of Investigation. Court records are public information and can be obtained from county court offices and some states have statewide online court records. When checking for prior arrests or previous court actions, the facility should check for misdemeanors as well as felonies. Driving records are available from the State Department of Motor Vehicles. A social security trace is a report, derived from credit bureau records that will return all current and reported addresses for the last seven to ten years on a specific individual based on his or her social security number. If there are alternate names (aliases) these are also reported. State child abuse registries can be accessed at http://www.hunter.cuny.edu/socwork/nrcfcpp/downloads/policy-issues/State_Child_Abuse_Registries
.pdf. Sex offender registries can be accessed at http://www
.prevent-abuse-now.com/register.htm. Companies also offer background check services. The National Association of Professional Background Screeners (http://www.napbs.com) provides a directory of their membership.

For more information on state licensing requirements regarding criminal background screenings, see the National Association for Regulatory Administration’s (NARA) current Licensing Study at http://www.naralicensing.org.

TYPE OF FACILITY: Center; Large Family Child Care Home; Small Family Child Care Home

REFERENCES:

1. Privacy Rights Clearinghouse. 2011. Fact sheet 16: Employment background checks: A jobseeker’s guide. http://www.privacyrights.org/fs/fs16-bck.htm.

1.3 Pre-service Qualifications

1.3.1 Director’s Qualifications

STANDARD 1.3.1.1: General Qualifications of Directors

The director of a center enrolling fewer than sixty children should be at least twenty-one-years-old and should have all the following qualifications:

Have a minimum of a Baccalaureate degree with at least nine credit-bearing hours of specialized college-level course work in administration, leadership, or management, and at least twenty-four credit-bearing hours of specialized college-level course work in early childhood education, child development, elementary education, or early childhood special education that addresses child development, learning from birth through kindergarten, health and safety, and collaboration with consultants OR documents meeting an appropriate combination of relevant education and work experiences (6);
A valid certificate of successful completion of pediatric first aid that includes CPR;
Knowledge of health and safety resources and access to education, health, and mental health consultants;
Knowledge of community resources available to children with special health care needs and the ability to use these resources to make referrals or achieve interagency coordination;
Administrative and management skills in facility operations;
Capability in curriculum design and implementation, ensuring that an effective curriculum is in place;
Oral and written communication skills;
Certificate of satisfactory completion of instruction in medication administration;
Demonstrated life experience skills in working with children in more than one setting;
Interpersonal skills;
Clean background screening.

Knowledge about parenting training/counseling and ability to communicate effectively with parents/guardians about developmental-behavioral issues, child progress, and in creating an intervention plan beginning with how the center will address challenges and how it will help if those efforts are not effective.

The director of a center enrolling more than sixty children should have the above and at least three years experience as a teacher of children in the age group(s) enrolled in the center where the individual will act as the director, plus at least six months experience in administration.

RATIONALE: The director of the facility is the team leader of a small business. Both administrative and child development skills are essential for this individual to manage the facility and set appropriate expectations. College-level coursework has been shown to have a measurable, positive effect on quality child care, whereas experience per se has not (1-3,5).

The director of a center plays a pivotal role in ensuring the day-to-day smooth functioning of the facility within the framework of appropriate child development principles and knowledge of family relationships (6).

The well-being of the children, the confidence of the parents/guardians of children in the facility’s care, and the high morale and consistent professional growth of the staff depend largely upon the knowledge, skills, and dependable presence of a director who is able to respond to long-range and immediate needs and able to engage staff in decision-making that affects their day-to-day practice (5,6). Management skills are important and should be viewed primarily as a means of support for the key role of educational leadership that a director provides (6). A skilled director should know how to use early care and education consultants, such as health, education, mental health, and community resources and to identify specialized personnel to enrich the staff’s understanding of health, development, behavior, and curriculum content. Past experience working in an early childhood setting is essential to running a facility.

Life experience may include experience rearing one’s own children or previous personal experience acquired in any child care setting. Work as a hospital aide or at a camp for children with special health care needs would qualify, as would experience in school settings. This experience, however, must be supplemented by competency-based training to determine and provide whatever new skills are needed to care for children in child care settings.

COMMENTS: The profession of early childhood education is being informed by research on the association of developmental outcomes with specific practices. The exact combination of college coursework and supervised experience is still being developed. For example, the National Association for the Education of Young Children (NAEYC) has published the Standards for Early Childhood Professional Preparation Programs (4). The National Child Care Association (NCCA) has developed a curriculum based on administrator competencies; more information on the NCCA is available at http://www.nccanet.org.

TYPE OF FACILITY: Center

REFERENCES:

1. Roupp, R., J. Travers, F. M., Glantz, C. Coelen. 1979. Children at the center: Summary findings and their implications. Vol. 1 of Final report of the National day care study. Cambridge, MA: Abt Associates.

2. Howes, C. 1997. Children’s experiences in center-based child care as a function of teacher background and adult:child ratio. Merrill-Palmer Q 43:404-24.

3. Helburn, S., ed. 1995. Cost, quality and child outcomes in child care centers. Denver, CO: University of Colorado at Denver.

4. National Association for the Education of Young Children (NAEYC). 2009. Standards for early childhood professional preparation programs. Washington, DC: NAEYC. http://www.naeyc
.org/files/naeyc/file/positions/ProfPrepStandards09.pdf.

5. Fiene, R. 2002. 13 indicators of quality child care: Research update. Washington, DC: U.S. Department of Health and Human Services, Office of the Assistant Secretary for Planning and Evaluation. http://aspe.hhs.gov/hsp/ccquality-ind02/.

6. National Association for the Education of Young Children (NAEYC). 2007. NAEYC early childhood program standards and accreditation criteria: The mark of quality in early childhood education. Washington, DC: NAEYC.

STANDARD 1.3.1.2: Mixed Director/Teacher Role

Centers enrolling thirty or more children should employ a non-teaching director. Centers with fewer than thirty children may employ a director who teaches as well.

RATIONALE: The duties of a director of a facility with more than thirty children do not allow the director to be involved in the classroom in a meaningful way.

COMMENTS: This standard does not prohibit the director from occasional substitute teaching, as long as the substitute teaching is not a regular and significant duty. Occasional substitute teaching may keep the director in touch with the caregivers’/teachers’ issues.

TYPE OF FACILITY: Center

1.3.2 Caregiver’s/Teacher’s and Other Staff Qualifications

STANDARD 1.3.2.1: Differentiated Roles

Centers should employ a caregiving/teaching staff for direct work with children in a progression of roles, as listed in descending order of responsibility:

Program administrator or training/curriculum specialists;
Lead teachers;
Teachers;
Assistant teachers or teacher aides.

Each role with increased responsibility should require increased educational qualifications and experience, as well as increased salary.

RATIONALE: A progression of roles enables centers to offer career ladders rather than dead-end jobs. It promotes a mix of college-trained staff with other members of a child’s own community who might have entered at the aide level and moved into higher roles through college or on-the-job training.

Professional education and pre-professional in-service training programs provide an opportunity for career progression and can lead to job and pay upgrades and fewer turnovers. Turnover rates in child care positions in 1997 averaged 30% (3).

COMMENTS: Early childhood professional knowledge must be required whether programs are in private centers, public schools, or other settings. The National Association for the Education of Young Children’s (NAEYC) Academy of Early Childhood Programs recommends a multi-level training program that addresses pre-employment educational requirements and continuing education requirements for entry-level assistants, caregivers/teachers, and administrators. It also establishes a table of qualifications for accredited programs (1). The NAEYC requirements include development of an employee compensation plan to increase salaries and benefits to ensure recruitment and retention of qualified staff and continuity of relationships (2). The NAEYC’s recommendations should be consulted in conjunction with the standards in this document.

TYPE OF FACILITY: Center

REFERENCES:

1. National Association for the Education of Young Children (NAEYC). 2005. Accreditation criteria and procedures of the National Academy of Early Childhood Programs. Washington, DC: NAEYC.

2. National Association for the Education of Young Children (NAEYC). 2009. Standards for early childhood professional preparation programs. Washington, DC: NAEYC. http://www.naeyc
.org/files/naeyc/file/positions/ProfPrepStandards09.pdf.

3. Whitebook, M., C. Howes, D. Phillips. 1998. Worthy work, unlivable wages: The national child care staffing study, 1988-1997. Washington, DC: Center for the Child Care Workforce.

STANDARD 1.3.2.2: Qualifications of Lead Teachers and Teachers

Lead teachers and teachers should be at least twenty-one years of age and should have at least the following education, experience, and skills:

A Bachelor’s degree in early childhood education, school-age care, child development, social work, nursing, or other child-related field, or an associate’s degree in early childhood education and currently working towards a bachelor’s degree;
A minimum of one year on-the-job training in providing a nurturing indoor and outdoor environment and meeting the child’s out-of-home needs;
One or more years of experience, under qualified supervision, working as a teacher serving the ages and developmental abilities of the children in care;
A valid certificate in pediatric first aid, including CPR;
Thorough knowledge of normal child development and early childhood education, as well as knowledge of indicators that a child is not developing typically;
The ability to respond appropriately to children’s needs;
The ability to recognize signs of illness and safety/injury hazards and respond with prevention interventions;
Oral and written communication skills;
Medication administration training (8).

Every center, regardless of setting, should have at least one licensed/certified lead teacher (or mentor teacher) who meets the above requirements working in the child care facility at all times when children are in care.

Additionally, facilities serving children with special health care needs associated with developmental delay should employ an individual who has had a minimum of eight hours of training in inclusion of children with special health care needs.

RATIONALE: Child care that promotes healthy development is based on the developmental needs of infants, toddlers, and preschool children. Caregivers/teachers are chosen for their knowledge of, and ability to respond appropriately to, the needs of children of this age generally, and the unique characteristics of individual children (1-4). Both early childhood and special educational experience are useful in a center. Caregivers/teachers that have received formal education from an accredited college or university have shown to have better quality of care and outcomes of programs. Those teachers with a four-year college degree exhibit optimal teacher behavior and positive effects on children (6).

Caregivers/teachers are more likely to administer medications than to perform CPR. Seven thousand children per year require emergency department visits for problems related to cough and cold medication (7).

COMMENTS: The profession of early childhood education is being informed by the research on early childhood brain development, child development practices related to child outcomes (5). For additional information on qualifications for child care staff, refer to the Standards for Early Childhood Professional Preparation Programs from the National Association for the Education of Young Children (NAEYC) (4). Additional information on the early childhood education profession is available from the Center for the Child Care Workforce (CCW).

TYPE OF FACILITY: Center

REFERENCES:

1. National Institute of Child Health and Human Development (NICHD) Early Child Care Research Network. 1996. Characteristics of infant child care: Factors contributing to positive caregiving. Early Child Res Q 11:269-306.

2. Bredekamp, S., C. Copple, eds. 1997. Developmentally appropriate practice in early childhood programs. Rev ed. Washington, DC: National Association for the Education of Young Children.

3. U.S. Department of Justice. 2011. Americans with Disabilities Act. http://www.ada.gov.

5. Committee on Integrating the Science of Early Childhood Development, Board on Children, Youth, and Families. 2000. From neurons to neighborhoods. Ed. J. P. Shonkoff, D. A. Phillips. Washington, DC: National Academy Press.

6. Kagan, S. L., K. Tarrent, K. Kauerz. 2008. The early care and education teaching workforce at the fulcrum, 44-47, 90-91. New York: Teachers College Press.

7. U.S. Department of Health and Human Services. 2008. CDC study estimates 7,000 pediatric emergency departments visits linked to cough and cold medication: Unsupervised ingestion accounts for 66 percent of incidents. Centers for Disease Control and Prevention (CDC). http://www.cdc.gov/media/pressrel/2008/r080128.htm.

8. American Academy of Pediatrics, Council on School Health. 2009. Policy statement: Guidance for the administration of medication in school. Pediatrics 124:1244-51.

STANDARD 1.3.2.3: Qualifications for Assistant Teachers, Teacher Aides, and Volunteers

Assistant teachers and teacher aides should be at least eighteen years of age, have a high school diploma or GED, and participate in on-the-job training, including a structured orientation to the developmental needs of young children and access to consultation, with periodic review, by a supervisory staff member. At least 50% of all assistant teachers and teacher aides must have or be working on either a Child Development Associate (CDA) credential or equivalent, or an associate’s or higher degree in early childhood education/child development or equivalent (9).

Volunteers should be at least sixteen years of age and should participate in on-the-job training, including a structured orientation to the developmental needs of young children. Assistant teachers, teacher aides, and volunteers should work only under the continual supervision of lead teacher or teacher. Assistant teachers, teacher aides, and volunteers should never be left alone with children. Volunteers should not be counted in the child:staff ratio.

All assistant teachers, teacher aides, and volunteers should possess:

The ability to carry out assigned tasks competently under the supervision of another staff member;
An understanding of and the ability to respond appropriately to children’s needs;
Sound judgment;
Emotional maturity; and
Clearly discernible affection for and commitment to the well-being of children.

RATIONALE: While volunteers and students can be as young as sixteen, age eighteen is the earliest age of legal consent. Mature leadership is clearly preferable. Age twenty-one allows for the maturity necessary to meet the responsibilities of managing a center or independently caring for a group of children who are not one’s own.

Child care that promotes healthy development is based on the developmental needs of infants, toddlers, preschool, and school-age children. Caregivers/teachers should be chosen for their knowledge of, and ability to respond appropriately to, the general needs of children of this age and the unique characteristics of individual children (1,3-5).

Staff training in child development and/or early childhood education is related to positive outcomes for children. This training enables the staff to provide children with a variety of learning and social experiences appropriate to the age of the child. Everyone providing service to, or interacting with, children in a center contributes to the child’s total experience (8).

Adequate compensation for skilled workers will not be given priority until the skills required are recognized and valued. Teaching and caregiving requires skills to promote development and learning by children whose needs and abilities change at a rapid rate.

COMMENTS: Experience and qualifications used by the Child Development Associate (CDA) program and the National Child Care Association (NCCA) credentialing program, and included in degree programs with field placement are valued (10). Early childhood professional knowledge must be required whether programs are in private homes, centers, public schools, or other settings. Go to http://www
.cdacouncil.org/the-cda-credential/how-to-earn-a-cda/ to view appropriate training and qualification information on the CDA Credential.

The National Association for the Education of Young Children’s (NAEYC) National Academy for Early Childhood Program Accreditation, the National Early Childhood Program Accreditation (NECPA) and the National Association of Family Child Care (NAFCC) have established criteria for staff qualifications (2,6,7).

Caregivers/teachers who lack educational qualifications may be employed as continuously supervised personnel while they acquire the necessary educational qualifications if they have personal characteristics, experience, and skills in working with parents, guardians and children, and the potential for development on the job or in a training program.

States may have different age requirements for volunteers.

TYPE OF FACILITY: Center; Large Family Child Care Home

REFERENCES:

2. National Association for the Education of Young Children (NAEYC). 2005. Accreditation and criteria procedures of the National Academy of Early Childhood Programs. Washington, DC: NAEYC.

3. National Association for the Education of Young Children (NAEYC). 2009. Developmentally appropriate practice in early childhood programs serving children from birth through age 8. Washington, DC: NAEYC. http://www.naeyc.org/files/naeyc/file/positions/position statement Web.pdf.

4. U.S. Department of Justice. 2011. Americans with Disabilities Act. http://www.ada.gov.

5. National Association for the Education of Young Children (NAEYC). 2009. Standards for Early Childhood professional preparation programs. Washington, DC: NAEYC. http://www.naeyc
.org/files/naeyc/file/positions/ProfPrepStandards09.pdf.

6. National Child Care Association (NCCA). NCCA official Website. http://www.nccanet.org.

7. National Association for Family Child Care (NAFCC). NAFCC official Website. http://nafcc.net.

8. Da Ros-Voseles, D., S. Fowler-Haughey. 2007. Why children’s dispositions should matter to all teachers. Young Children (September): 1-7. http://www.naeyc.org/files/yc/file/200709/
DaRos-Voseles.pdf.

9. National Association for the Education of Young Children (NAEYC). Candidacy requirements. http://www.naeyc.org/academy/pursuing/candreq/.

10. Council for Professional Recognition. 2011. How to obtain a CDA. http://www.cdacouncil.org/the-cda-credential/
how-to-earn-a-cda/.

STANDARD 1.3.2.4: Additional Qualifications for Caregivers/Teachers Serving Children Three to Thirty-Five Months of Age

Caregivers/teachers should be prepared to work with infants and toddlers and, when asked, should be knowledgeable and demonstrate competency in tasks associated with caring for infants and toddlers:

Diapering and toileting;
Bathing;
Feeding, including support for continuation of breastfeeding;
Holding;
Comforting;
Practicing safe sleep practices to reduce the risk of Sudden Infant Death Syndrome (SIDS) (3);
Providing warm, consistent, responsive caregiving and opportunities for child-initiated activities;
Stimulating communication and language development and pre-literacy skills through play, shared reading, song, rhyme, and lots of talking;
Promoting cognitive, physical, and social emotional development;
Preventing shaken baby syndrome/abusive head trauma;
Promoting infant mental health;
Promoting positive behaviors;
Setting age-appropriate limits with respect to safety, health, and mutual respect;
Using routines to teach children what to expect from caregivers/teachers and what caregivers/teachers expect from them.

Caregivers/teachers should demonstrate knowledge of development of infants and toddlers as well as knowledge of indicators that a child is not developing typically; knowledge of the importance of attachment for infants and toddlers, the importance of communication and language development, and the importance of nurturing consistent relationships on fostering positive self-efficacy development.

To help manage atypical or undesirable behaviors of children, caregivers/teachers, in collaboration with parents/guardians, should seek professional consultation from the child’s primary care provider, an early childhood mental health professional, or an early childhood mental health consultant.

RATIONALE: The brain development of infants is particularly sensitive to the quality and consistency of interpersonal relationships. Much of the stimulation for brain development comes from the responsive interactions of caregivers/teachers and children during daily routines. Children need to be allowed to pursue their interests within safe limits and to be encouraged to reach for new skills (1-7).

COMMENTS: Since early childhood mental health professionals are not always available to help with the management of challenging behaviors in the early care and education setting early childhood mental health consultants may be able to help. The consultant should be viewed as an important part of the program’s support staff and should collaborate with all regular classroom staff, consultants, and other staff. Qualified potential consultants may be identified by contacting mental health and behavioral providers in the local area, as well as accessing the National Mental Health Information Center (NMHIC) at http://store.samhsa.gov/
mhlocator/ and Healthy Child Care America (HCCA) at http://www.healthychildcare.org/Contacts.html.

TYPE OF FACILITY: Center; Large Family Child Care Home; Small Family Child Care Home

REFERENCES:

1. Shore, R. 1997. Rethinking the brain: New insights into early development. New York: Families and Work Inst.

2. National Forum on Early Childhood Policy and Programs, National Scientific Council on the Developing Child. 2007. A science-based framework for early childhood policy: Using evidence to improve outcomes in learning, behavior, and health for vulnerable children. http://developingchild.harvard.edu/index.php/library/reports_and_working_papers/policy_framework/.

3. Moon, R. Y., T. Calabrese, L. Aird. 2008. Reducing the risk of sudden infant death syndrome in child care and changing provider practices: Lessons learned from a demonstration project. Pediatrics 122:788-98.

4. Fiene, R. 2002. 13 indicators of quality child care: Research update. Washington, DC: U.S. Department of Health and Human Services, Office of the Assistant Secretary for Planning and Evaluation. http://aspe.hhs.gov/hsp/ccquality-ind02/.

5. Centers for Disease Control and Prevention. Learn the signs. Act early. http://www.cdc.gov/ncbddd/actearly/.

6. Shonkoff, J. P., D. A. Phillips, eds. 2000. From neurons to neighborhoods: The science of early childhood development. Washington, DC: National Academy Press.

7. Cohen, J., N. Onunaku, S. Clothier, J. Poppe. 2005. Helping young children succeed: Strategies to promote early childhood social and emotional development. Washington, DC: National Conference of State Legislatures; Zero to Three. http://main
.zerotothree.org/site/DocServer/help_yng_child_succeed.pdf.

STANDARD 1.3.2.5: Additional Qualifications for Caregivers/Teachers Serving Children Three to Five Years of Age

Caregivers/teachers should demonstrate the ability to apply their knowledge and understanding of the following to children three to five years of age within the program setting:

Typical and atypical development of three- to five-year-old children;
Social and emotional development of children, including children’s development of independence, their ability to adapt to their environment and cope with stress, problem solve and engage in conflict resolution, and successfully establish friendships;
Cognitive, language, early literacy, scientific inquiry, and mathematics development of children;
Cultural backgrounds of the children in the facility’s care;
Talking to parents/guardians about observations and concerns and referrals to parents/guardians;
Changing needs of populations served, e.g., culture, income, etc.

To help manage atypical or undesirable behaviors of children three to five years of age, caregivers/teachers serving this age group should seek professional consultation, in collaboration with parents/guardians, from the child’s primary care provider, a mental health professional, a child care health consultant, or an early childhood mental health consultant.

RATIONALE: Three- and four-year-old children continue to depend on the affection, physical care, intellectual guidance, and emotional support of their caregivers/teachers (1,2).

A supportive, nurturing setting that supports a demonstration of feelings and accepts regression as part of development continues to be vital for preschool children. Preschool children need help building a positive self-image, a sense of self as a person of value from a family and a culture of which they are proud. Children should be enabled to view themselves as coping, problem-solving, competent, passionate, expressive, and socially connected to peers and staff (3).

TYPE OF FACILITY: Center; Large Family Child Care Home; Small Family Child Care Home

REFERENCES:

1. National Institute of Child Health and Human Development (NICHD) Early Child Care Research Network. 1999. Child outcomes when child center classes meet recommended standards for quality. Am J Public Health 89:1072-77.

2. Shore, R. 1997. Rethinking the brain: New insights into early development. New York: Families and Work Inst.

3. Fiene, R. 2002. 13 indicators of quality child care: Research update. Washington, DC: U.S. Department of Health and Human Services, Office of the Assistant Secretary for Planning and Evaluation. http://aspe.hhs.gov/hsp/ccquality-ind02/.

STANDARD 1.3.2.6: Additional Qualifications for Caregivers/Teachers Serving School-Age Children

Caregivers/teachers should demonstrate knowledge about and competence with the social and emotional needs and developmental tasks of five- to twelve-year old children, be able to recognize and appropriately manage difficult behaviors, and know how to implement a socially and cognitively enriching program that has been developed with input from parents/guardians. Issues that are significant within school-age programs include having a sense of community, bullying, sexuality, electronic media, and social networking.

With this age group as well, caregivers/teachers, in collaboration with parents/guardians, should seek professional consultation from the child’s primary care provider, a mental health professional, a child care health consultant, or an early childhood mental health consultant to help manage atypical or undesirable behaviors.

RATIONALE: A school-age child develops a strong, secure sense of identity through positive experiences with adults and peers (1,2). An informal, enriching environment that encourages self-paced cultivation of interests and relationships promotes the self-worth of school-age children (1). Balancing free exploration with organized activities including homework assistance and tutoring among a group of children also supports healthy emotional and social development (1,3).

When children display behaviors that are unusual or difficult to manage, caregivers/teachers should work with parents/guardians to seek a remedy that allows the child to succeed in the child care setting, if possible (4).

COMMENTS: The first resource for addressing behavior problems is the child’s primary care provider. School personnel, including professional serving school-based health clinics may also be able to provide valuable insights. Support from a mental health professional may be needed. If the child’s primary care provider cannot help or obtain help from a mental health professional, the caregiver/teacher and the family may need an early childhood mental health consultant to advise about appropriate management of the child. Local mental health agencies or pediatric departments of medical schools may offer help from child psychiatrists, psychologists, other mental health professionals skilled in the issues of early childhood, and pediatricians who have a subspecialty in developmental and behavioral pediatrics. Local or area education agencies serving children with special health or developmental needs may be useful. State Title V (Children with Special Health Care Needs) may be contacted. All state Maternal Child Health (MCH) programs are required to have a toll-free number to link consumers to appropriate programs for children with special health care needs. The toll-free number listing is located at https://perfdata.hrsa
.gov/MCHB/MCHReports/search/program/prgsch16.asp. Dismissal from the program should be the last resort and only after consultation with the parent/guardian(s).

TYPE OF FACILITY: Center; Large Family Child Care Home; Small Family Child Care Home

REFERENCES:

1. Deschenes, S. N., A. Arbreton, P. M. Little, C. Herrera, J. B. Grossman, H. B. Weiss, D. Lee. 2010. Engaging older youth: Program and city-level strategies to support sustained participation in out-of-school time. http://www.hfrp.org/out-of-school-time/publications-resources/engaging-older-youth-program-and-city
-level-strategies-to-support-sustained-participation-in-out-of
-school-time/.

2. New York State Department of Social Services, Cornell Cooperative Extension. 2004. A parent’s guide to child care for school-age children. National Network for Child Care. http://www
.nncc.org/choose.quality.care/parents.sac.html#anchor68421/
. references

4. Harvard Family Research Project. 2010. Family engagement as a systemic, sustained, and integrated strategy to promote student achievement. http://www.hfrp.org/publications-resources/browse
-our-publications/family-engagement-as-a-systemic-sustained
-and-integrated-strategy-to-promote-student-achievement/.

STANDARD 1.3.2.7: Qualifications and Responsibilities for Health Advocates

Each facility should designate at least one administrator or staff person as the health advocate to be responsible for policies and day-to-day issues related to health, development, and safety of individual children, children as a group, staff, and parents/guardians. In large centers it may be important to designate health advocates at both the center and classroom level. The health advocate should be the primary contact for parents/guardians when they have health concerns, including health-related parent/guardian/staff observations, health-related information, and the provision of resources. The health advocate ensures that health and safety is addressed, even when this person does not directly perform all necessary health and safety tasks.

The health advocate should also identify children who have no regular source of health care, health insurance, or positive screening tests with no referral documented in the child’s health record. The health advocate should assist the child’s parent/guardian in locating a Medical Home by referring them to a primary care provider who offers routine child health services.

For centers, the health advocate should be licensed/certified/credentialed as a director or lead teacher or should be a health professional, health educator, or social worker who works at the facility on a regular basis (at least weekly).

The health advocate should have documented training in the following:

Control of infectious diseases, including Standard Precautions, hand hygiene, cough and sneeze etiquette, and reporting requirements;
Childhood immunization requirements, record-keeping, and at least quarterly review and follow-up for children who need to have updated immunizations;
Child health assessment form review and follow-up of children who need further medical assessment or updating of their information;
How to plan for, recognize, and handle an emergency;
Poison awareness and poison safety;
Recognition of safety, hazards, and injury prevention interventions;
Safe sleep practices and the reduction of the risk of Sudden Infant Death Syndrome (SIDS);
How to help parents/guardians, caregivers/teachers, and children cope with death, severe injury, and natural or man-made catastrophes;
Recognition of child abuse, neglect/child maltreatment, shaken baby syndrome/abusive head trauma (for facilities caring for infants), and knowledge of when to report and to whom suspected abuse/neglect;
Facilitate collaboration with families, primary care providers, and other health service providers to create a health, developmental, or behavioral care plan;
Implementing care plans;
Recognition and handling of acute health related situations such as seizures, respiratory distress, allergic reactions, as well as other conditions as dictated by the special health care needs of children;
Medication administration;
Recognizing and understanding the needs of children with serious behavior and mental health problems;
Maintaining confidentiality;
Healthy nutritional choices;
The promotion of developmentally appropriate types and amounts of physical activity;
How to work collaboratively with parents/guardians and family members;
How to effectively seek, consult, utilize, and collaborate with child care health consultants, and in partnership with a child care health consultant, how to obtain information and support from other education, mental health, nutrition, physical activity, oral health, and social service consultants and resources;
Knowledge of community resources to refer children and families who need health services including access to State Children’s Health Insurance (SCHIP), importance of a primary care provider and medical home, and provision of immunizations and Early Periodic Screening, Diagnosis, and Treatment (EPSDT).

RATIONALE: The effectiveness of an intentionally designated health advocate in improving the quality of performance in a facility has been demonstrated in all types of early childhood settings (1). A designated caregiver/teacher with health training is effective in developing an ongoing relationship with the parents/guardians and a personal interest in the child (2,3). Caregivers/teachers who are better trained are more able to prevent, recognize, and correct health and safety problems. An internal advocate for issues related to health and safety can help integrate these concerns with other factors involved in formulating facility plans.

Children may be current with required immunizations when they enroll, but they sometimes miss scheduled immunizations thereafter. Because the risk of vaccine-preventable disease increases in group settings, assuring appropriate immunizations is an essential responsibility in child care. Caregivers/teachers should contact their child care health consultant or the health department if they have a question regarding immunization updates/schedules. They can also provide information to share with parents/guardians about the importance of vaccines.

Child health records are intended to provide information that indicates that the child has received preventive health services to stay well, and to identify conditions that might interfere with learning or require special care. Review of the information on these records should be performed by someone who can use the information to plan for the care of the child, and recognize when updating of the information by the child’s primary care provider is needed. Children must be healthy to be ready to learn. Those who need accommodation for health problems or are susceptible to vaccine-preventable diseases will suffer if the staff of the child care program is unable to use information provided in child health records to ensure that the child’s needs are met (5,6).

COMMENTS: The director should assign the health advocate role to a staff member who seems to have an interest, aptitude, and training in this area. This person need not perform all the health and safety tasks in the facility but should serve as the person who raises health and safety concerns. This staff person has designated responsibility for seeing that plans are implemented to ensure a safe and healthful facility (1).

A health advocate is a regular member of the staff of a center or large or small family child care home, and is not the same as the child care health consultant recommended in Child Care Health Consultants, Standard 1.6.0.1. The health advocate works with a child care health consultant on health and safety issues that arise in daily interactions (4). For small family child care homes, the health advocate will usually be the caregiver/teacher. If the health advocate is not the child’s caregiver/teacher, the health advocate should work with the child’s caregiver/teacher. The person who is most familiar with the child and the child’s family will recognize atypical behavior in the child and support effective communication with parents/guardians.

A plan for personal contact with parents/guardians should be developed, even though this contact will not be possible daily. A plan for personal contact and documentation of a designated caregiver/teacher as health advocate will ensure specific attempts to have the health advocate communicate directly with caregivers/teachers and families on health-related matters.

The immunization record/compliance review may be accomplished by manual review of child health records or by use of software programs that use algorithms with the currently recommended vaccine schedules and service intervals to test the dates when a child received recommended services and the child’s date of birth to identify any gaps for which referrals should be made. On the Website of the Centers for Disease Control and Prevention (CDC), individual vaccine recommendations for children six years of age and younger can be checked at http://www.cdc.gov/vaccines/recs/scheduler/catchup.htm.

TYPE OF FACILITY: Center; Large Family Child Care Home; Small Family Child Care Home

REFERENCES:

1. Ulione, M. S. 1997. Health promotion and injury prevention in a child development center. J Pediatr Nurs 12:148-54.

2. Kendrick, A. S., R. Kaufmann, K. P. Messenger, eds. 1991. Healthy young children: A manual for programs. Washington, DC: National Association for the Education of Young Children.

3. Murph, J. R., S. D. Palmer, D. Glassy, eds. 2005. Health in child care: A manual for health professionals. 4th ed. Elk Grove Village, IL: American Academy of Pediatrics.

4. Alkon, A., J. Bernzweig, K. To, J. K. Mackie, M. Wolff, J. Elman. 2008. Child care health consultation programs in California: Models, services, and facilitators. Public Health Nurs 25:126-39.

5. Centers for Disease Control and Prevention (CDC). 2011. Immunization schedules. http://www.cdc.gov/vaccines/recs/schedules/.

6. Hagan, J. F., J. S. Shaw, P. M. Duncan, eds. 2008. Bright futures: Guidelines for health supervision of infants, children, and adolescents. 3rd ed. Elk Grove Village, IL: American Academy of Pediatrics.

1.3.3 Family Child Care Home Caregiver/Teacher Qualifications

STANDARD 1.3.3.1: General Qualifications of Family Child Care Caregivers/Teachers to Operate a Family Child Care Home

All caregivers/teachers in large and small family child care homes should be at least twenty-one years of age, hold an official credential as granted by the authorized state agency, meet the general requirements specified in Standard 1.3.2.4 through Standard 1.3.2.6, based on ages of the children served, and those in Section 1.3.3, and should have the following education, experience, and skills:

Current accreditation by the National Association for Family Child Care (NAFCC) (including entry-level qualifications and participation in required training) and a college certificate representing a minimum of three credit hours of early childhood education leadership or master caregiver/teacher training or hold an Associate’s degree in early childhood education or child development;
A provider who has been in the field less than twelve months should be in the self-study phase of NAFCC accreditation;
A valid certificate in pediatric first aid, including CPR;
Pre-service training in health management in child care, including the ability to recognize signs of illness, knowledge of infectious disease prevention and safety injury hazards;
If caring for infants, knowledge on safe sleep practices including reducing the risk of sudden infant death syndrome (SIDS) and prevention of shaken baby syndrome/abusive head trauma (including how to cope with a crying infant);
Knowledge of normal child development, as well as knowledge of indicators that a child is not developing typically;
The ability to respond appropriately to children’s needs;
Good oral and written communication skills;
Willingness to receive ongoing mentoring from other teachers;
Pre-service training in business practices;
Knowledge of the importance of nurturing adult-child relationships on self-efficacy development;
Medication administration training (6).

Additionally, large family child care home caregivers/teachers should have at least one year of experience serving the ages and developmental abilities of the children in their large family child care home.

Assistants, aides, and volunteers employed by a large family child care home should meet the qualifications specified in Standard 1.3.2.3.

RATIONALE: In both large and small family child care homes, staff members must have the education and experience to meet the needs of the children in care (7). Small family child care home caregivers/teachers often work alone and are solely responsible for the health and safety of small numbers of children in their care.

Most SIDS deaths in child care occur on the first day of care or within the first week; unaccustomed prone (tummy) sleeping increases the risk of SIDS eighteen times (3). Shaken baby syndrome/abusive head trauma is completely preventable. Pre-service training and frequent refresher training can prevent deaths (4).

Age eighteen is the earliest age of legal consent. Mature leadership is clearly preferable. Age twenty-one is more likely to be associated with the level of maturity necessary to independently care for a group of children who are not one’s own.

The NAFCC has established an accreditation process to enhance the level of quality and professionalism in small and large family child care (2).

COMMENTS: A large family child care home caregiver/teacher, caring for more than six children and employing one or more assistants, functions as the primary caregiver as well as the facility director. An operator of a large family-child-care home should be offered training relevant to the management of a small child care center, including training on providing a quality work environment for employees.

For more information on assessing the work environment of family child care employees, see Creating Better Family Child Care Jobs: Model Work Standards, a publication by the Center for the Child Care Workforce (CCW) (1).

TYPE OF FACILITY: Large Family Child Care Home; Small Family Child Care Home

REFERENCES:

1. Center for Child Care Workforce. 1999. Creating better family child care jobs: Model work standards. Washington, DC: Center for Child Care Workforce.

2. National Association for Family Child Care. NAFCC official Website. http://nafcc.net.

4. Centers for Disease Control and Prevention. Learn the signs. Act early. http://www.cdc.gov/ncbddd/actearly/.

5. U.S. Department of Health and Human Services. 2008. CDC study estimates 7,000 pediatric emergency departments visits linked to cough and cold medication: Unsupervised ingestion accounts for 66 percent of incidents. Centers for Disease Control and Prevention (CDC). http://www.cdc.gov/media/pressrel/2008/r080128.htm.

6. American Academy of Pediatrics, Council on School Health. 2009. Policy statement: Guidance for the administration of medication in school. Pediatrics 124:1244-51.

7. National Association for Family Child Care (NAFCC). 2005. Quality standards for NAFCC accreditation. 4th ed. Salt Lake City, UT: NAFCC.

STANDARD 1.3.3.2: Support Networks for Family Child Care

Large and small family child care home caregivers/teachers should have active membership in a national, and/or state and local early care and education organization(s). National organizations addressing concerns of family child care home caregivers/teachers include the American Academy of Pediatrics (AAP), the National Association for Family Child Care (NAFCC), and the National Association for the Education of Young Children (NAEYC). In addition, belonging to a local network of family child care home caregivers/teachers that offers education, training and networking opportunities provides the opportunity to focus on local needs. Child care resource and referral agencies may provide additional support networks for caregivers/teachers that include professional development opportunities and information about electronic networking.

RATIONALE: Membership in peer professional organizations shows a commitment to quality child care and also provides a conduit for information to otherwise isolated caregivers/teachers. Membership in a family child care association and attendance at meetings indicate the desire to gain new knowledge about how to work with children (1).

COMMENTS: For more information about family child care associations, contact the NAFCC at http://nafcc.net and/or the NAEYC at http://www.naeyc.org. Also, caregivers/teachers should check to see if their state has specific accreditation standards.

TYPE OF FACILITY: Large Family Child Care Home; Small Family Child Care Home

REFERENCES:

1. Fiene, R. 2002. 13 indicators of quality child care: Research update. Washington, DC: U.S. Department of Health and Human Services, Office of the Assistant Secretary for Planning and Evaluation. http://aspe.hhs.gov/hsp/ccquality-ind02/.

1.4 Professional Development/Training

1.4.1 Pre-service Training

STANDARD 1.4.1.1: Pre-service Training

In addition to the credentials listed in Standard 1.3.1.1, upon employment, a director or administrator of a center or the lead caregiver/teacher in a family child care home should provide documentation of at least thirty clock-hours of pre-service training. This training should cover health, psychosocial, and safety issues for out-of-home child care facilities. Small family child care home caregivers/teachers may have up to ninety days to secure training after opening except for training on basic health and safety procedures and regulatory requirements.

All directors or program administrators and caregivers/teachers should document receipt of pre-service training prior to working with children that includes the following content on basic program operations:

Typical and atypical child development and appropriate best practice for a range of developmental and mental health needs including knowledge about the developmental stages for the ages of children enrolled in the facility;
Positive ways to support language, cognitive, social, and emotional development including appropriate guidance and discipline;
Developing and maintaining relationships with families of children enrolled, including the resources to obtain supportive services for children’s unique developmental needs;
Procedures for preventing the spread of infectious disease, including hand hygiene, cough and sneeze etiquette, cleaning and disinfection of toys and equipment, diaper changing, food handling, health department notification of reportable diseases, and health issues related to having animals in the facility;
Teaching child care staff and children about infection control and injury prevention through role modeling;
Safe sleep practices including reducing the risk of Sudden Infant Death Syndrome (SIDS) (infant sleep position and crib safety);
Shaken baby syndrome/abusive head trauma prevention and identification, including how to cope with a crying/fussy infant;
Poison prevention and poison safety;
Immunization requirements for children and staff;
Common childhood illnesses and their management, including child care exclusion policies and recognizing signs and symptoms of serious illness;
Reduction of injury and illness through environmental design and maintenance;
Knowledge of U.S. Consumer Product Safety Commission (CPSC) product recall reports;
Staff occupational health and safety practices, such as proper procedures, in accordance with Occupational Safety and Health Administration (OSHA) bloodborne pathogens regulations;
Emergency procedures and preparedness for disasters, emergencies, other threatening situations (including weather-related, natural disasters), and injury to infants and children in care;
Promotion of health and safety in the child care setting, including staff health and pregnant workers;
First aid including CPR for infants and children;
Recognition and reporting of child abuse and neglect in compliance with state laws and knowledge of protective factors to prevent child maltreatment;
Nutrition and age-appropriate child-feeding including food preparation, choking prevention, menu planning, and breastfeeding supportive practices;
Physical activity, including age-appropriate activities and limiting sedentary behaviors;
Prevention of childhood obesity and related chronic diseases;
Knowledge of environmental health issues for both children and staff;
Knowledge of medication administration policies and practices;
Caring for children with special health care needs, mental health needs, and developmental disabilities in compliance with the Americans with Disabilities Act (ADA);
Strategies for implementing care plans for children with special health care needs and inclusion of all children in activities;
Positive approaches to support diversity;
Positive ways to promote physical and intellectual development.

RATIONALE: The director or program administrator of a center or large family child care home or the small family child care home caregiver/teacher is the person accountable for all policies. Basic entry-level knowledge of health and safety and social and emotional needs is essential to administer the facility. Caregivers/teachers should be knowledgeable about infectious disease and immunizations because properly implemented health policies can reduce the spread of disease, not only among the children but also among staff members, family members, and in the greater community (1). Knowledge of injury prevention measures in child care is essential to control known risks. Pediatric first aid training that includes CPR is important because the director or small family child care home caregiver/teacher is fully responsible for all aspects of the health of the children in care. Medication administration and knowledge about caring for children with special health care needs is essential to maintaining the health and safety of children with special health care needs. Most SIDS deaths in child care occur on the first day of child care or within the first week due to unaccustomed prone (on the stomach) sleeping; the risk of SIDS increases eighteen times when an infant who sleeps supine (on the back) at home is placed in the prone position in child care (2). Shaken baby syndrome/abusive head trauma is completely preventable. It is crucial for caregivers/teachers to be knowledgeable of both syndromes and how to prevent them before they care for infants. Early childhood expertise is necessary to guide the curriculum and opportunities for children in programs (3). The minimum of a Child Development Associate credential with a system of required contact hours, specific content areas, and a set renewal cycle in addition to an assessment requirement would add significantly to the level of care and education for children.

The National Association for the Education of Young Children (NAEYC), a leading organization in child care and early childhood education, recommends annual training based on the needs of the program and the pre-service qualifications of staff (4). Training should address the following areas:

Health and safety (specifically reducing the risk of SIDS, infant safe sleep practices, shaken baby syndrome/abusive head trauma), and poison prevention and poison safety;
Child growth and development, including motor development and appropriate physical activity;
Nutrition and feeding of children;
Planning learning activities for all children;
Guidance and discipline techniques;
Linkages with community services;
Communication and relations with families;
Detection and reporting of child abuse and neglect;
Advocacy for early childhood programs;
Professional issues (5).

In the early childhood field there is often “crossover” regarding professional preparation (pre-service programs) and ongoing professional development (in-service programs). This field is one in which entry-level requirements differ across various sectors within the field (e.g., nursing, family support, and bookkeeping are also fields with varying entry-level requirements). In early childhood, the requirements differ across center, home, and school based settings. An individual could receive professional preparation (pre-service) to be a teaching staff member in a community-based organization and receive subsequent education and training as part of an ongoing professional development system (in-service). The same individual could also be pursuing a degree for a role as a teacher in a program for which licensure is required—this in-service program would be considered pre-service education for the certified teaching position. Therefore, the labels pre-service and in-service must be seen as related to a position in the field, and not based on the individual’s professional development program (5).

COMMENTS: Training in infectious disease control and injury prevention may be obtained from a child care health consultant, pediatricians, or other qualified personnel of children’s and community hospitals, managed care companies, health agencies, public health departments, EMS and fire professionals, pediatric emergency room physicians, or other health and safety professionals in the community.

For more information about training opportunities, contact the local Child Care Resource and Referral Agency (CCRRA), the local chapter of the American Academy of Pediatrics (AAP) (AAP provides online SIDS and medication administration training), the Healthy Child Care America Project, the National Resource Center for Health and Safety in Child Care and Early Education (NRC), or the National Training Institute for Child Care Health Consultants (NTI) at the University of North Carolina at Chapel Hill. California Childcare Health Program (CCHP) has free curricula for health and safety for caregivers/teachers to become child care health advocates. The curriculum (English and Spanish) is free to download on the Web at http://www.ucsfchildcare
health.org/html/pandr/trainingcurrmain.htm, and is based on NTI’s curriculum for child care health consultants. Online training for caregivers/teachers is also available through some state agencies.

For more information on social-emotional training, contact the Center on the Social and Emotional Foundations for Early Learning (CSEFEL) at http://csefel.vanderbilt.edu.

TYPE OF FACILITY: Center; Large Family Child Care Home; Small Family Child Care Home

REFERENCES:

1. Hayney M. S., J. C. Bartell. 2005. An immunization education program for childcare providers. J of School Health 75:147-49.

2. Moon R. Y., R. P. Oden. 2003. Back to sleep: Can we influence child care providers? Pediatrics 112:878-82.

4. Ritchie, S., B. Willer. 2008. Teachers: A guide to the NAEYC early childhood program standard and related accreditation criteria. Washington, DC: National Association for the Education of Young Children (NAEYC).

5. National Association for the Education of Young Children. 2010. Definition of early childhood professional development, 12. Eds. M. S. Donovan, J. D. Bransford, J. W. Pellegrino. Washington, DC: National Academy Press.

1.4.2 Orientation Training

STANDARD 1.4.2.1: Initial Orientation of All Staff

All new full-time staff, part-time staff and substitutes should be oriented to the policies listed in Standard 9.2.1.1 and any other aspects of their role. The topics covered and the dates of orientation training should be documented. Caregivers/teachers should also receive continuing education each year, as specified in Continuing Education, Standard 1.4.4.1 through Standard 1.4.6.2.

RATIONALE: Orientation ensures that all staff members receive specific and basic training for the work they will be doing and are informed about their new responsibilities. Because of frequent staff turnover, directors should institute orientation programs on a regular basis (3).

Orientation and ongoing training are especially important for aides and assistant teachers, for whom pre-service educational requirements are limited. Entry into the field at the level of aide or assistant teacher should be attractive and facilitated so that capable members of the families and cultural groups of the children in care can enter the field. Training ensures that staff members are challenged and stimulated, have access to current knowledge (2), and have access to education that will qualify them for new roles.

Use of videos and other passive methods of training should be supplemented by interactive training approaches that help verify content of training has been learned (4).

Health training for child care staff protects the children in care, staff, and the families of the children enrolled. Infectious disease control in child care helps prevent spread of infectious disease in the community. Outbreaks of infectious diseases and intestinal parasites in young children in child care have been shown to be associated with community outbreaks (1).

Child care health consultants can be an excellent resource for providing health and safety orientation or referrals to resources for such training.

COMMENTS: Many states have pre-service education and experience qualifications for caregivers/teachers by role and function. Offering a career ladder and utilizing employee incentives such as Teacher Education and Compensation Helps (TEACH) will attract individuals into the child care field, where labor is in short supply. Colleges, accrediting bodies, and state licensing agencies should examine teacher preparation guidelines and substantially increase the health content of early childhood professional preparation.

Child care staff members are important figures in the lives of the young children in their care and in the well-being of families and the community. Child care staff training should include new developments in children’s health. For example; a new training program could discuss up-to-date information on the prevention of obesity and its impact on early onset of chronic diseases.

TYPE OF FACILITY: Center; Large Family Child Care Home; Small Family Child Care Home

REFERENCES:

1. Crowley, A. A. 1990. Health services in child care day-care centers: A survey. J Pediatr Health Care 4:252-59.

2. Moon R. Y., R. P. Oden. 2003. Back to sleep: Can we influence child care providers? Pediatrics 112:878-82.

4. National Association for the Education of Young Children (NAEYC). 2008. Leadership and management: A guide to the NAEYC early childhood program standards and related accreditation criteria. Washington, DC: NAEYC.

STANDARD 1.4.2.2: Orientation for Care of Children with Special Health Care Needs

When a child care facility enrolls a child with special health care needs, the facility should ensure that all staff members have been oriented in understanding that child’s special health care needs and have the skills to work with that child in a group setting.

Caregivers/teachers in small family child care homes, who care for a child with special health care needs, should meet with the parents/guardians and meet or speak with the child’s primary care provider (if the parent/guardian has provided prior, informed, written consent) or a child care health consultant to ensure that the child’s special health care needs will be met in child care and to learn how these needs may affect his/her developmental progression or play with other children.

In addition to Orientation Training, Standard 1.4.2.1, the orientation provided to staff in child care facilities should be based on the special health care needs of children who will be assigned to their care. All staff oriented for care of children with special health needs should be knowledgeable about the care plans created by the child’s primary care provider in their medical home as well as any care plans created by other health professionals and therapists involved in the child’s care. A template for a care plan for children with special health care needs can be found in Appendix O. Child care health consultants can be an excellent resource for providing health and safety orientation or referrals to resources for such training. This training may include, but is not limited to, the following topics:

Positioning for feeding and handling, and risks for injury for children with physical/mental disabilities;
Toileting techniques;
Knowledge of special treatments or therapies (e.g., PT, OT, speech, nutrition/diet therapies, emotional support and behavioral therapies, medication administration, etc.) the child may need/receive in the child care setting;
Proper use and care of the individual child’s adaptive equipment, including how to recognize defective equipment and to notify parents/guardians that repairs are needed;
How different disabilities affect the child’s ability to participate in group activities;
Methods of helping the child with special health care needs or behavior problems to participate in the facility’s programs, including physical activity programs;
Role modeling, peer socialization, and interaction;
Behavior modification techniques, positive behavioral supports for children, promotion of self-esteem, and other techniques for managing behavior;
Grouping of children by skill levels, taking into account the child’s age and developmental level;
Health services or medical intervention for children with special health care problems;
Communication methods and needs of the child;
Dietary specifications for children who need to avoid specific foods or for children who have their diet modified to maintain their health, including support for continuation of breastfeeding;
Medication administration (for emergencies or on an ongoing basis);
Recognizing signs and symptoms of impending illness or change in health status;
Recognizing signs and symptoms of injury;
Understanding temperament and how individual behavioral differences affect a child’s adaptive skills, motivation, and energy;
Potential hazards of which staff should be aware;
Collaborating with families and outside service providers to create a health, developmental, and behavioral care plan for children with special needs;
Awareness of when to ask for medical advice and recommendations for non-emergent issues that arise in school (e.g., head lice, worms, diarrhea);
Knowledge of professionals with skills in various conditions, e.g., total communication for children with deafness, beginning orientation and mobility training for children with blindness (including arranging the physical environment effectively for such children), language promotion for children with hearing-impairment and language delay/disorder, etc.;
How to work with parents/guardians and other professionals when assistive devices or medications are not consistently brought to the child care program or school;
How to safely transport a child with special health care needs.

RATIONALE: A basic understanding of developmental disabilities and special care requirements of any child in care is a fundamental part of any orientation for new employees. Training is an essential component to ensure that staff members develop and maintain the needed skills. A comprehensive curriculum is required to ensure quality services. However, lack of specialized training for staff does not constitute grounds for exclusion of children with disabilities (1).

Staff members need information about how to help children use and maintain adaptive equipment properly. Staff members need to understand how and why various items are used and how to check for malfunctions. If a problem occurs with adaptive equipment, the staff must recognize the problem and inform the parent/guardian so that the parent/guardian can notify the health care or equipment provider of the problem and request that it be remedied. While the parent/guardian is responsible for arranging for correction of equipment problems, child care staff must be able to observe and report the problem to the parent/guardian. Routine care of adaptive and treatment equipment, such as nebulizers, should be taught.

COMMENTS: These training topics are generally applicable to all personnel serving children with special health care needs and apply to child care facilities. The curriculum may vary depending on the type of facility, classifications of disabilities of the children in the facility, and ages of the children. The staff is assumed to have the training described in Orientation Training, Standard 1.4.2.1, including child growth and development. These additional topics will extend their basic knowledge and skills to help them work more effectively with children who have special health care needs and their families. The number of hours offered in any in-service training program should be determined by the staff’s experience and professional background. Service plans in small family child care homes may require a modified implementation plan.

The parent/guardian is responsible for solving equipment problems. The parent/guardian can request that the child care facility remedy the problem directly if the caregiver/teacher has been trained on the maintenance and repair of the equipment and if the staff agrees to do it.

TYPE OF FACILITY: Center; Large Family Child Care Home; Small Family Child Care Home

REFERENCES:

1. U.S. Department of Justice. 2011. Americans with Disabilities Act. http://www.ada.gov.

STANDARD 1.4.2.3: Orientation Topics

During the first three months of employment, the director of a center or the caregiver/teacher in a large family home should document, for all full-time and part-time staff members, additional orientation in, and the employees’ satisfactory knowledge of, the following topics:

Recognition of symptoms of illness and correct documentation procedures for recording symptoms of illness. This should include the ability to perform a daily health check of children to determine whether any children are ill or injured and, if so, whether a child who is ill should be excluded from the facility;
Exclusion and readmission procedures and policies;
Cleaning, sanitation, and disinfection procedures and policies;
Procedures for administering medication to children and for documenting medication administered to children;
Procedures for notifying parents/guardians of an infectious disease occurring in children or staff within the facility;
Procedures and policies for notifying public health officials about an outbreak of disease or the occurrence of a reportable disease;
Emergency procedures and policies related to unintentional injury, medical emergency, and natural disasters;
Procedure for accessing the child care health consultant for assistance;
Injury prevention strategies and hazard identification procedures specific to the facility, equipment, etc.;
Proper hand hygiene.

Before being assigned to tasks that involve identifying and responding to illness, staff members should receive orientation training on these topics. Small family child care home caregivers/teachers should not commence operation before receiving orientation on these topics in pre-service training (1).

RATIONALE: Children in child care are frequently ill (2). Staff members responsible for child care must be able to recognize illness and injury, carry out the measures required to prevent the spread of communicable diseases, handle ill and injured children appropriately, and appropriately administer required medications (4). Hand hygiene is one of the most important means of preventing spread of infectious disease (3).

TYPE OF FACILITY: Center; Large Family Child Care Home; Small Family Child Care Home

REFERENCES:

2. Aronson, S. S., T. R. Shope, eds. 2009. Managing infectious diseases in child care and schools: A quick reference guide. 2nd ed. Elk Grove Village, IL: American Academy of Pediatrics.

3. Centers for Disease Control and Prevention (CDC). 2011. Handwashing: Clean hands save lives. http://www.cdc.gov/handwashing/.

4. American Academy of Pediatrics, Council on School Health. 2009. Policy statement: Guidance for the administration of medication in school. Pediatrics 124:1244-51.

1.4.3 First Aid and CPR Training

STANDARD 1.4.3.1: First Aid and CPR Training for Staff

The director of a center or a large family child care home and the caregiver/teacher in a small family child care home should ensure all staff members involved in providing direct care have documentation of satisfactory completion of training in pediatric first aid and pediatric CPR skills. Pediatric CPR skills should be taught by demonstration, practice, and return demonstration to ensure the technique can be performed in an emergency. These skills should be current according to the requirement specified for retraining by the organization that provided the training.

At least one staff person who has successfully completed training in pediatric first aid that includes CPR should be in attendance at all times with a child whose special care plan indicates an increased risk of needing respiratory or cardiac resuscitation.

Records of successful completion of training in pediatric first aid should be maintained in the personnel files of the facility.

RATIONALE: To ensure the health and safety of children in a child care setting, someone who is qualified to respond to life-threatening emergencies must be in attendance at all times (1). A staff trained in pediatric first aid, including pediatric CPR, coupled with a facility that has been designed or modified to ensure the safety of children, can mitigate the consequences of injury, and reduce the potential for death from life-threatening conditions. Knowledge of pediatric first aid, including pediatric CPR which addresses management of a blocked airway and rescue breathing, and the confidence to use these skills, are critically important to the outcome of an emergency situation.

Small family child care home caregivers/teachers often work alone. They must have the necessary skills to manage emergencies while caring for all the children in the group.

Children with special health care needs who have compromised airways may need to be accompanied to child care with nurses who are able to respond to airway problems (e.g., the child who has a tracheostomy and needs suctioning).

First aid skills are the most likely tools caregivers/teachers will need. Minor injuries are common. For emergency situations that require attention from a health professional, first aid procedures can be used to control the situation until a health professional can provide definitive care. However, management of a blocked airway (choking) is a life-threatening emergency that cannot wait for emergency medical personnel to arrive on the scene (2).

Documentation of current certification of satisfactory completion of pediatric first aid and demonstration of pediatric CPR skills in the facility assists in implementing and in monitoring for proof of compliance.

COMMENTS: The recommendations from the American Heart Association (AHA) changed in 2010 from “A-B-C” (Airway, Breathing, Chest compressions) to “C-A-B” (Chest compressions, Airway, Breathing) for adults and pediatric patients (children and infants, excluding newborns). Except for newborns, the ratio of chest compressions to ventilations in the 2010 guidelines is 30:2. CPR skills are lost without practice and ongoing education (3,5).

The most common renewal cycle required by organizations that offer pediatric first aid and pediatric CPR training is to require successful completion of training every three years (4), though the AHA requires successful completion of CPR class every two years.

Inexpensive self-learning kits that require only thirty minutes to review the skills of pediatric CPR with a video and an inflatable manikin are available from the AHA. See “Infant CPR Anytime” and “Family and Friends CPR Anytime” at http://www.heart.org/HEARTORG/.

Child care facilities should consider having an Automated External Defibrillators (AED) on the child care premises for potential use with adults. The use of AEDs with children would be rare.

TYPE OF FACILITY: Center; Large Family Child Care Home; Small Family Child Care Home

REFERENCES:

1. Alkon, A., P. J. Kaiser, J. M. Tschann, W. T. Boyce, J. L. Genevro, M. Chesney. 1994. Injuries in child-care centers: Rates, severity, and etiology. Pediatrics 94:1043-46.

2. Stevens, P. B., K. A. Dunn. 1994. Use of cardiopulmonary resuscitation by North Carolina day care providers. J School Health 64:381-83.

3. American Heart Association (AHA). 2010 AHA guidelines for cardiopulmonary resuscitation and emergency cardiovascular care science. Circulation 122: S640-56.

4. Aronson, S. S., ed. 2007. Pediatric first aid for caregivers and teachers. Rev. 1st ed. Elk Grove Village, IL: American Academy of Pediatrics; Sudbury, MA: Jones and Bartlett.

5. American Heart Association (AHA). 2010. Hands-only CPR. http://handsonlycpr.org.

STANDARD 1.4.3.2: Topics Covered in First Aid Training

First aid training should present an overview of Emergency Medical Services (EMS), accessing EMS, poison center services, accessing the poison center, safety at the scene, and isolation of body substances. First aid instruction should include, but not be limited to, recognition and first response of pediatric emergency management in a child care setting of the following situations:

Management of a blocked airway and rescue breathing for infants and children with return demonstration by the learner (pediatric CPR);
Abrasions and lacerations;
Bleeding, including nosebleeds;
Burns;
Fainting;
Poisoning, including swallowed, skin or eye contact, and inhaled;
Puncture wounds, including splinters;
Injuries, including insect, animal, and human bites;
Poison control;
Shock;
Seizure care;
Musculoskeletal injury (such as sprains, fractures);
Dental and mouth injuries/trauma;
Head injuries, including shaken baby syndrome/abusive head trauma;
Allergic reactions, including information about when epinephrine might be required;
Asthmatic reactions, including information about when rescue inhalers must be used;
Eye injuries;
Loss of consciousness;
Electric shock;
Drowning;
Heat-related injuries, including heat exhaustion/heat stroke;
Cold related injuries, including frostbite;
Moving and positioning injured/ill persons;
Illness-related emergencies (such as stiff neck, inexplicable confusion, sudden onset of blood-red or purple rash, severe pain, temperature above 101°F [38.3°C] orally, above 102°F [38.9°C] rectally, or 100°F [37.8°C] or higher taken axillary [armpit] or measured by an equivalent method, and looking/acting severely ill);
Standard Precautions;
Organizing and implementing a plan to meet an emergency for any child with a special health care need;
Addressing the needs of the other children in the group while managing emergencies in a child care setting;
Applying first aid to children with special health care needs.

RATIONALE: First aid for children in the child care setting requires a more child-specific approach than standard adult-oriented first aid offers. To ensure the health and safety of children in a child care setting, someone who is qualified to respond to common injuries and life-threatening emergencies must be in attendance at all times. A staff trained in pediatric first aid, including pediatric CPR, coupled with a facility that has been designed or modified to ensure the safety of children, can reduce the potential for death and disability. Knowledge of pediatric first aid, including the ability to demonstrate pediatric CPR skills, and the confidence to use these skills, are critically important to the outcome of an emergency situation (1).

Small family child care home caregivers/teachers often work alone and are solely responsible for the health and safety of children in care. Such caregivers/teachers must have pediatric first aid competence.

COMMENTS: Other children will have to be supervised while the injury is managed. Parental notification and communication with emergency medical services must be carefully planned. First aid information can be obtained from the American Academy of Pediatrics (AAP) at http://www
.aap.org and the American Heart Association (AHA) at http://www.heart.org/HEARTORG/.

TYPE OF FACILITY: Center; Large Family Child Care Home; Small Family Child Care Home

REFERENCES:

1. Aronson, S. S., ed. 2007. Pediatric first aid for caregivers and teachers. Rev. 1st ed. Elk Grove Village, IL: American Academy of Pediatrics; Sudbury, MA: Jones and Bartlett.

STANDARD 1.4.3.3: CPR Training for Swimming and Water Play

Facilities that have a swimming pool should require at least one staff member with current documentation of successful completion of training in infant and child (pediatric) CPR (Cardiopulmonary Resuscitation) be on duty at all times during business hours.

At least one of the caregivers/teachers, volunteers, or other adults who is counted in the child:staff ratio for swimming and water play should have documentation of successful completion of training in basic water safety, proper use of swimming pool rescue equipment, and infant and child CPR according to the criteria of the American Red Cross or the American Heart Association (AHA).

For small family child care homes, the person trained in water safety and CPR should be the caregiver/teacher. Written verification of successful completion of CPR and lifesaving training, water safety instructions, and emergency procedures should be kept on file.

RATIONALE: Drowning involves cessation of breathing and rarely requires cardiac resuscitation of victims. Nevertheless, because of the increased risk for cardiopulmonary arrest related to wading and swimming, the facility should have personnel trained to provide CPR and to deal promptly with a life-threatening drowning emergency. During drowning, cold exposure provides the possibility of protection of the brain from irreversible damage associated with respiratory and cardiac arrest. Children drown in as little as two inches of water. The difference between a life and death situation is the submersion time. Thirty seconds can make a difference. The timely administration of resuscitation efforts by a caregiver/teacher trained in water safety and CPR is critical. Studies have shown that prompt rescue and the presence of a trained resuscitator at the site can save about 30% of the victims without significant neurological consequences (1).

TYPE OF FACILITY: Center; Large Family Child Care Home; Small Family Child Care Home

REFERENCES:

1. Aronson, S. S., ed. 2007. Pediatric first aid for caregivers and teachers. Rev. 1st ed. Elk Grove Village, IL: American Academy of Pediatrics; Sudbury, MA: Jones and Bartlett.

1.4.4 Continuing Education/Professional Development

STANDARD 1.4.4.1: Continuing Education for Directors and Caregivers/Teachers in Centers and Large Family Child Care Homes

All directors and caregivers/teachers of centers and large family child care homes should successfully complete at least thirty clock-hours per year of continuing education/professional development in the first year of employment, sixteen clock-hours of which should be in child development programming and fourteen of which should be in child health, safety, and staff health. In the second and each of the following years of employment at a facility, all directors and caregivers/teachers should successfully complete at least twenty-four clock-hours of continuing education based on individual competency needs and any special needs of the children in their care, sixteen hours of which should be in child development programming and eight hours of which should be in child health, safety, and staff health.

Programs should conduct a needs assessment to identify areas of focus, trainer qualifications, adult learning strategies, and create an annual professional development plan for staff based on the needs assessment. The effectiveness of training should be evident by the change in performance as measured by accreditation standards or other quality assurance systems.

RATIONALE: Because of the nature of their caregiving/teaching tasks, caregivers/teachers must attain multifaceted knowledge and skills. Child health and employee health are integral to any education/training curriculum and program management plan. Planning and evaluation of training should be based on performance of the staff member(s) involved. Too often, staff members make training choices based on what they like to learn about (their “wants”) and not the areas in which their performance should be improved (their “needs”). Participation in training does not ensure that the participant will master the information and skills offered in the training experience. Therefore, caregiver/teacher change in behavior or the continuation of appropriate practice resulting from the training, not just participation in training, should be assessed by supervisors and directors (4).

In addition to low child:staff ratio, group size, age mix of children, and stability of caregiver/teacher, the training/education of caregivers/teachers is a specific indicator of child care quality (2). Most skilled roles require training related to the functions and responsibilities the role requires. Staff members who are better trained are better able to prevent, recognize, and correct health and safety problems. The number of training hours recommended in this standard reflects the central focus of caregivers/teachers on child development, health, and safety.

Children may come to child care with identified special health care needs or special needs may be identified while attending child care, so staff should be trained in recognizing health problems as well as in implementing care plans for previously identified needs. Medications are often required either on an emergent or scheduled basis for a child to safely attend child care. Caregivers/teachers should be well trained on medication administration and appropriate policies should be in place.

The National Association for the Education of Young Children (NAEYC), a leading organization in child care and early childhood education, recommends annual training/professional development based on the needs of the program and the pre-service qualifications of staff (1). Training should address the following areas:

Promoting child growth and development correlated with developmentally appropriate activities;
Infant care;
Recognizing and managing minor illness and injury;
Managing the care of children who require the special procedures listed in Standard 3.5.0.2;
Medication administration;
Business aspects of the small family child care home;
Planning developmentally appropriate activities in mixed age groupings;
Nutrition for children in the context of preparing nutritious meals for the family;
Age-appropriate size servings of food and child feeding practices;
Acceptable methods of discipline/setting limits;
Organizing the home for child care;
Preventing unintentional injuries in the home (e.g., falls, poisoning, burns, drowning);
Available community services;
Detecting, preventing, and reporting child abuse and neglect;
Advocacy skills;
Pediatric first aid, including pediatric CPR;
Methods of effective communication with children and parents/guardians;
Socio-emotional and mental health (positive approaches with consistent and nurturing relationships);
Evacuation and shelter-in-place drill procedures;
Occupational health hazards;
Infant safe sleep environments and practices;
Standard Precautions;
Shaken baby syndrome/abusive head trauma;
Dental issues;
Age-appropriate nutrition and physical activity.

There are few illnesses for which children should be excluded from child care. Decisions about management of ill children are facilitated by skill in assessing the extent to which the behavior suggesting illness requires special management (3). Continuing education on managing infectious diseases helps prepare caregivers/teachers to make these decisions devoid of personal biases (5). Recommendations regarding responses to illnesses may change (e.g., H1N1), so caregivers/teachers need to know where they can find the most current information. All caregivers/teachers should be trained to prevent, assess, and treat injuries common in child care settings and to comfort an injured child and children witnessing an injury.

COMMENTS: Tools for assessment of training needs are part of the accreditation self-study tools available from the NAEYC, the National Association for Family Child Care (NAFCC), National Early Childhood Professional Accreditation (NECPA), Association for Christian Education International (ACEI), National AfterSchool Association (NAA), and the National Child Care Association (NCCA). Successful completion of training can be measured by a performance test at the end of training and by ongoing evaluation of performance on the job.

Resources for training on health and safety issues include:

State and local health departments (health education, environmental health and sanitation, nutrition, public health nursing departments, fire and EMS, etc.);
Networks of child care health consultants;
Graduates of the National Training Institute for Child Care Health Consultants (NTI);
Child care resource and referral agencies;
University Centers for Excellence on Disabilities;
Local children’s hospitals;
State and local chapters of:
1. American Academy of Pediatrics (AAP), including AAP Chapter Child Care Contacts;
2. American Academy of Family Physicians (AAFP);
3. American Nurses’ Association (ANA);
4. American Public Health Association (APHA);
5. Visiting Nurse Association (VNA);
6. National Association of Pediatric Nurse Practitioners (NAPNAP);
7. National Association for the Education of Young Children (NAEYC);
8. National Association for Family Child Care (NAFCC);
9. National Association of School Nurses (NASN);
10. National Training Institute for Child Care Health Consultants (NTI);
11. Emergency Medical Services for Children (EMSC) National Resource Center;
12. National Association for Sport and Physical Education (NASPE);
13. American Dietetic Association (ADA);
14. American Association of Poison Control Centers (AAPCC).

For nutrition training, facilities should check that the nutritionist/registered dietician (RD), who provides advice, has experience with, and knowledge of, child development, infant and early childhood nutrition, school-age child nutrition, prescribed nutrition therapies, food service and food safety issues in the child care setting. Most state Maternal and Child Health (MCH) programs, Child and Adult Care Food Programs (CACFP), and Special Supplemental Nutrition Programs for Women, Infants, and Children (WIC) have a nutrition specialist on staff or access to a local consultant. If this nutrition specialist has knowledge and experience in early childhood and child care, facilities might negotiate for this individual to serve or identify someone to serve as a consultant and trainer for the facility.

Many resources are available for nutritionists/RDs who provide training in food service and nutrition. Some resources to contact include:

Local, county, and state health departments to locate MCH, CACFP, or WIC programs;
State university and college nutrition departments;
Home economists at utility companies;
State affiliates of the American Dietetic Association;
State and regional affiliates of the American Public Health Association;
The American Association of Family and Consumer Services;
National Resource Center for Health and Safety in Child Care and Early Education;
Nutritionist/RD at a hospital;
High school home economics teachers;
The Dairy Council;
The local American Heart Association affiliate;
The local Cancer Society;
The Society for Nutrition Education;
The local Cooperative Extension office;
Local community colleges and trade schools.

Nutrition education resources may be obtained from the Food and Nutrition Information Center at http://fnic.nal.usda.gov. The staff’s continuing education in nutrition may be supplemented by periodic newsletters and/or literature (frequently bilingual) or audiovisual materials prepared or recommended by the Nutrition Specialist.

Caregivers/teachers should have a basic knowledge of special health care needs, supplemented by specialized training for children with special health care needs. The type of special health care needs of the children in care should influence the selection of the training topics. The number of hours offered in any in-service training program should be determined by the experience and professional background of the staff, which is best achieved through a regular staff conference mechanism.

Financial support and accessibility to training programs requires attention to facilitate compliance with this standard. Many states are using federal funds from the Child Care and Development Block Grant to improve access, quality, and affordability of training for early care and education professionals. College courses, either online or face to face, and training workshops can be used to meet the training hours requirement. These training opportunities can also be conducted on site at the child care facility. Completion of training should be documented by a college transcript or a training certificate that includes title/content of training, contact hours, name and credentials of trainer or course instructor and date of training. Whenever possible the submission of documentation that shows how the learner implemented the concepts taught in the training in the child care program should be documented. Although on-site training can be costly, it may be a more effective approach than participation in training at a remote location.

Projects and Outreach: Early Childhood Research and Evaluation Projects, Midwest Child Care Research Consortium at http://ccfl.unl.edu/projects_outreach/projects/current/ecp/mwcrc.php, identifies the number of hours for education of staff and fourteen indicators of quality from a study conducted in four Midwestern states.

TYPE OF FACILITY: Center; Large Family Child Care Home

REFERENCES:

1. National Association for the Education of Young Children (NAEYC). 2009. Standards for early childhood professional preparation programs. Washington, DC: NAEYC. http://www.naeyc
.org/files/naeyc/file/positions/ProfPrepStandards09.pdf.

2. Whitebook, M., C. Howes, D. Phillips. 1998. Worthy work, unlivable wages: The National child care staffing study, 1988-1997. Washington, DC: Center for the Child Care Workforce.

3. Crowley, A. A. 1990. Health services in child care day care centers: A survey. J Pediatr Health Care 4:252-59.

5. Aronson, S. S., T. R. Shope, eds. 2009. Managing infectious diseases in child care and schools: A quick reference guide. 2nd ed. Elk Grove Village, IL: American Academy of Pediatrics.

STANDARD 1.4.4.2: Continuing Education for Small Family Child Care Home Caregivers/Teachers

Small family child care home caregivers/teachers should have at least thirty clock-hours per year (2) of continuing education in areas determined by self-assessment and, where possible, by a performance review of a skilled mentor or peer reviewer.

RATIONALE: In addition to low child:staff ratio, group size, age mix of children, and continuity of caregiver/teacher, the training/education of caregivers/teachers is a specific indicator of child care quality (1). Most skilled roles require training related to the functions and responsibilities the role requires. Caregivers/teachers who engage in on-going training are more likely to decrease morbidity and mortality in their setting (3) and are better able to prevent, recognize, and correct health and safety problems.

Children may come to child care with identified special health care needs or may develop them while attending child care, so staff must be trained in recognizing health problems as well as in implementing care plans for previously identified needs.

Because of the nature of their caregiving/teaching tasks, caregivers/teachers must attain multifaceted knowledge and skills. Child health and employee health are integral to any education/training curriculum and program management plan. Planning and evaluation of training should be based on performance of the caregiver/teacher. Provision of workshops and courses on all facets of a small family child care business may be difficult to access and may lead to caregivers/teachers enrolling in training opportunities in curriculum related areas only. Too often, caregivers/teachers make training choices based on what they like to learn about (their “wants”) and not the areas in which their performance should be improved (their “needs”).

Small family child care home caregivers/teachers often work alone and are solely responsible for the health and safety of small numbers of children in care. Peer review is part of the process for accreditation of family child care and can be valuable in assisting the caregiver/teacher in the identification of areas of need for training. Self-evaluation may not identify training needs or focus on areas in which the caregiver/teacher is particularly interested and may be skilled already.

COMMENTS: The content of continuing education for small family child care home caregivers/teachers should include the following topics:

Promoting child growth and development correlated with developmentally appropriate activities;
Infant care;
Recognizing and managing minor illness and injury;
Managing the care of children who require the special procedures listed in Standard 3.5.0.2;
Medication administration;
Business aspects of the small family child care home;
Planning developmentally appropriate activities in mixed age groupings;
Nutrition for children in the context of preparing nutritious meals for the family;
Age-appropriate size servings of food and child feeding practices;
Acceptable methods of discipline/setting limits;
Organizing the home for child care;
Preventing unintentional injuries in the home (falls, poisoning, burns, drowning);
Available community services;
Detecting, preventing, and reporting child abuse and neglect;
Advocacy skills;
Pediatric first aid, including pediatric CPR;
Methods of effective communication with children and parents/guardians;
Socio-emotional and mental health (positive approaches with consistent and nurturing relationships);
Evacuation and shelter-in-place drill procedures;
Occupational health hazards;
Infant-safe sleep environments and practices;
Standard Precautions;
Shaken baby syndrome/abusive head trauma;
Dental issues;
Age-appropriate nutrition and physical activity.

Small family child care home caregivers/teachers should maintain current contact lists of community pediatric primary care providers, specialists for health issues of individual children in their care and child care health consultants who could provide training when needed.

In-home training alternatives to group training for small family child care home caregivers/teachers are available, such as distance courses on the Internet, listening to audiotapes or viewing media (e.g., DVDs) with self-checklists. These training alternatives provide more flexibility for caregivers/teachers who are remote from central training locations or have difficulty arranging coverage for their child care duties to attend training. Nevertheless, gathering family child care home caregivers/teachers for training when possible provides a break from the isolation of their work and promotes networking and support. Satellite training via down links at local extension service sites, high schools, and community colleges scheduled at convenient evening or weekend times is another way to mix quality training with local availability and some networking.

TYPE OF FACILITY: Small Family Child Care Home

REFERENCES:

1. Whitebook, M., C. Howes, D. Phillips. 1998. Worthy work, unlivable wages: The national child care staffing study, 1988-1997. Washington, DC: Center for the Child Care Workforce.

2. The National Association of Family Child Care (NAFCC). 2005. Quality standards for NAFCC accreditation. 4th ed. Salt Lake City, UT: NAFCC. http://www.nafcc.org/documents/QualStd.pdf.

1.4.5 Specialized Training/Education

STANDARD 1.4.5.1: Training of Staff Who Handle Food

All staff members with food handling responsibilities should obtain training in food service and safety. The director of a center or a large family child care home or the designated supervisor for food service should be a certified food protection manager or equivalent as demonstrated by completing an accredited food protection manager course. Small family child care personnel should secure training in food service and safety appropriate for their setting.

RATIONALE: Outbreaks of foodborne illness have occurred in many settings, including child care facilities. Some of these outbreaks have led to fatalities and severe disabilities. Young children are particularly susceptible to foodborne illness, due to their body size and immature immune systems. Because large centers serve more meals daily than many restaurants do, the supervisors of food handlers in these settings should have successfully completed food service certification, and the food handlers in these settings should have successfully completed courses on appropriate food handling (1).

COMMENTS: Sponsors of the Child and Adult Care Food Program (CACFP) provide this training for some small family child care home caregivers/teachers. For training in food handling, caregivers/teachers should contact the state or local health department, or the delegate agencies that handle nutrition and environmental health inspection programs for the child care facility. Training for food workers is mandatory in some jurisdictions. Other sources for food safety information are the Food and Drug Administration (FDA) Food Code, family child care associations, child care resource and referral agencies, licensing agencies, and state departments of education.

TYPE OF FACILITY: Center; Large Family Child Care Home; Small Family Child Care Home

REFERENCES:

1. U.S. Department of Health and Human Services, Public Health Service, Food and Drug Administration (FDA). 2009. Food code 2009. College Park, MD: FDA. http://www.fda.gov/Food/FoodSafety/RetailFoodProtection/FoodCode/FoodCode2009/default.htm.

STANDARD 1.4.5.2: Child Abuse and Neglect Education

Caregivers/teachers should use child abuse and neglect prevention education to educate and establish child abuse and neglect prevention and recognition measures for the children, caregivers/teachers, and parents/guardians. The education should address physical, sexual, and psychological or emotional abuse and neglect. The dangers of shaking infants and toddlers and repeated exposure to domestic violence should be included in the education and prevention materials. Caregivers/teachers should also receive education on promoting protective factors to prevent child maltreatment. Caregivers/teachers should be able to identify signs of stress in families and assist families by providing support and linkages to resources when needed. Children with disabilities are at a higher risk of being abused. Special training in child abuse and neglect and children with disabilities should be provided (2).

Caregivers/teachers are mandatory reporters of child abuse or neglect. Caregivers/teachers should be trained in compliance with their state’s child abuse reporting laws. Child abuse reporting requirements are known and available from the child care regulation department in each state.

RATIONALE: Education about the manifestations of child maltreatment can increase the likelihood of appropriate reports to child protection agencies and law enforcement agencies (1-3).

COMMENTS: Child abuse and neglect materials should be designed for non-medical audiences. Resources are available from the American Academy of Pediatrics (AAP) at http://www.aap.org, the Child Welfare Information Gateway at http://www.childwelfare.gov, and Prevent Child Abuse America at http://www.preventchildabuse.org.

TYPE OF FACILITY: Center; Large Family Child Care Home; Small Family Child Care Home

REFERENCES:

1. American Academy of Pediatrics. Children’s health topics: Child abuse and neglect. http://www.aap.org/healthtopics/
childabuse.cfm.

2. New York State Office of Children and Family Services. Child abuse and children with disabilities: A New York State perspective. http://childabuse.tc.columbia.edu.

3. Giardino, A. P., E. R. Giardino. 2002. Recognition of child abuse for the mandated reporter. 3rd ed. St. Louis, MO: G. W. Medical Publishing.

STANDARD 1.4.5.3: Training on Occupational Risk Related to Handling Body Fluids

All caregivers/teachers who are at risk of occupational exposure to blood or other blood-containing body fluids should be offered hepatitis B immunizations and should receive annual training in Standard Precautions and exposure control planning. Training should be consistent with applicable standards of the Occupational Safety and Health Administration (OSHA) Standard 29 CFR 1910.1030, “Occupational Exposure to Bloodborne Pathogens” and local occupational health requirements and should include, but not be limited to:

Modes of transmission of bloodborne pathogens;
Standard Precautions;
Hepatitis B vaccine use according to OSHA requirements;
Program policies and procedures regarding exposure to blood/body fluid;
Reporting procedures under the exposure control plan to ensure that all first-aid incidents involving exposure are reported to the employer before the end of the work shift during which the incident occurs (1).

RATIONALE: Providing first aid in situations where blood is present is an intrinsic part of a caregiver’s/teacher’s job. Split lips, scraped knees, and other minor injuries associated with bleeding are common in child care.

Caregivers/teachers who are designated as responsible for rendering first aid or medical assistance as part of their job duties are covered by the scope of this standard.

COMMENTS: OSHA has model exposure control plan materials for use by child care facilities. Using the model exposure control plan materials, caregivers/teachers can prepare a plan to comply with the OSHA requirements. The model plan materials are available from regional offices of OSHA.

TYPE OF FACILITY: Center; Large Family Child Care Home

REFERENCES:

1. U.S. Department of Labor, Occupational Safety and Health Administration. 2008. Toxic and hazardous substances: Bloodborne pathogens. http://www.osha.gov/pls/oshaweb/owadisp.show
_document?p_table=STANDARDS&p_id=10051.

STANDARD 1.4.5.4: Education of Center Staff

Centers should educate staff to support the cultural, language, and ethnic backgrounds of children enrolled in the program. In addition, all staff members should participate in diversity training that will ensure respectful service delivery to all families and a staff that works well together (2).

RATIONALE: Young children’s identities cannot be separated from family, culture, and their home language. Children need both to see successful role models from their own ethnic and cultural groups and to develop the ability to relate to people who are different from themselves (1).

TYPE OF FACILITY: Center

REFERENCES:

2. National Association for the Education of Young Children (NAEYC). 2009. Quality benchmark for cultural competence project. Washington, DC: NAEYC. http://www.naeyc.org/files/naeyc/file/policy/state/QBCC_Tool.pdf.

1.4.6 Educational Leave/Compensation

STANDARD 1.4.6.1: Training Time and Professional Development Leave

A center, large family child care home or a support agency for a network of small family child care homes should make provisions for paid training time for staff to participate in required professional development (that includes training as well as education) during work hours, or reimburse staff for time spent attending professional development outside of regular work hours. Any hours worked in excess of forty hours in a week must be paid according to state and federal wage and hour regulations.

RATIONALE: Most caregivers/teachers work long hours and most are poorly paid (1). Using personal time for education required as a condition of employment is an unfair expectation until compensation for work done in child care is much more equitable. Many child care workers also employed in another vocation work at other jobs to make a living wage and would miss income from their other jobs or risk losing that employment. Additionally, the caregiver/teacher may incur stress in their family life when required to take time outside of child care hours to participate in work-related training.

COMMENTS: Professional development in child care often takes place when the participant is not released from other work-related duties, such as caring for children or answering phones. Providing substitutes and released time during work hours for such training is likely to enhance the effectiveness of training; and improve employee satisfaction/retention.

Large family child care homes employ staff in the same way as centers, except for size and location in a residence. For small family child care home caregivers/teachers, released time and compensation while engaged in training can be arranged only if the small family child care home caregiver/teacher is part of a support network that makes such arrangements. This standard does not apply to small family child care home caregivers/teachers independent of networks.

The Fair Labor Standard Act mandates payment of time and a half for all hours worked in excess of forty hours in a week.

TYPE OF FACILITY: Center; Large Family Child Care Homes; Small Family Child Care Homes

REFERENCES:

1. Center for the Child Care Workforce, American Federation of Teachers (AFT). 2009. Wage data: Early childhood workforce hourly wage data. 2009 ed. Washington, DC: AFT. http://www.ccw.org/storage/ccworkforce/documents/04-30-09 wwd fact sheet.pdf.

STANDARD 1.4.6.2: Payment for Continuing Education

Directors of centers and large family child care homes should arrange for continuing education that is paid for by the government, by charitable organizations, or by the facility, rather than by the employee. Small family child care home caregivers/teachers should avail themselves of training opportunities offered in their communities or online and claim their educational expenses as a business expense on tax forms.

RATIONALE: Caregivers/teachers often make low wages and may not be able to pay for mandated training. A majority of child care workers earnings are at or near minimum wage (1).

TYPE OF FACILITY: Center; Large Family Child Care Home; Small Family Child Care Home

REFERENCES:

1. Center for the Child Care Workforce, American Federation of Teachers. 2009. Wage data: Early childhood workforce hourly wage data. 2009 ed. Washington, DC: AFT. http://www.ccw.org/storage/ccworkforce/documents/04-30-09 wwd fact sheet.pdf.

1.5 Substitutes

STANDARD 1.5.0.1: Employment of Substitutes

Substitutes should be employed to ensure that child:staff ratios and requirements for direct supervision are maintained at all times. Substitutes and volunteers should be at least eighteen years of age and must meet the requirements specified throughout Standards 1.3.2.1-1.3.2.6. Those without licenses/certificates should work under direct supervision and should not be alone with a group of children.

A substitute should complete the same background screening processes as the caregiver/teacher. Obtaining substitutes to provide medical care for children with special health care needs is particularly challenging. A substitute nurse should be experienced in delivering the expected medical services. Decisions should be made on whether a parent/guardian will be allowed to provide needed on-site medical services. Substitutes should be aware of the care plans (including emergency procedures) for children with special health care needs.

RATIONALE: The risk to children from care by unqualified caregivers/teachers is the same whether the caregiver/teacher is a paid substitute or a volunteer (1).

COMMENTS: Substitutes are difficult to find, especially at the last minute. Planning for a competent substitute pool is essential for child care operation. Requiring substitutes for small family child care homes to obtain first aid and CPR certification forces small family child care home caregivers/teachers to close when they cannot be covered by a competent substitute. Since closing a child care home has a negative impact on the families and children they serve, systems should be developed to provide qualified alternative homes or substitutes for family child care home caregivers/teachers.

The lack of back-up for family child care home caregivers/teachers is an inherent liability in this type of care. Parents/guardians who use family child care must be sure they have suitable alternative care, such as family or friends, for situations in which the child’s usual caregiver/teacher cannot provide the service.

Substitutes should have orientation and training on basic health and safety topics. Substitutes should not have an infectious disease when providing care.

TYPE OF FACILITY: Center; Large Family Child Care Home; Small Family Child Care Home

REFERENCES:

1. National Association for Family Child Care (NAFCC). NAFCC official Website. http://nafcc.net.

STANDARD 1.5.0.2: Orientation of Substitutes

The director of any center or large family child care home and the small family child care home caregiver/teacher should provide orientation training to newly hired substitutes to include a review of ALL the program’s policies and procedures (listed below is a sample). This training should include the opportunity for an evaluation and a repeat demonstration of the training lesson. In all child care settings the orientation should be documented. Substitutes should have background screenings.

All substitutes should be oriented to, and demonstrate competence in, the tasks for which they will be responsible. On the first day a substitute caregiver/teacher should be oriented on the following topics:

Safe infant sleep practices if an infant is enrolled in the program;
Any emergency medical procedure/medication needs of the children;
Any nutrition needs of the children.

All substitute caregivers/teachers, during the first week of employment, should be oriented to, and should demonstrate competence in at least the following items:

The names of the children for whom the caregiver/teacher will be responsible, and their specific developmental needs;
The planned program of activities at the facility;
Routines and transitions;
Acceptable methods of discipline;
Meal patterns and safe food handling policies of the facility (special attention should be given to life-threatening food allergies);
Emergency health and safety procedures;
General health policies and procedures as appropriate for the ages of the children cared for, including but not limited to the following:
1. Hand hygiene techniques, including indications for hand hygiene;
2. Diapering technique, if care is provided to children in diapers, including appropriate diaper disposal and diaper changing techniques, use and wearing of gloves;
3. The practice of putting infants down to sleep positioned on their backs and on a firm surface along with all safe infant sleep practices to reduce the risk of Sudden Infant Death Syndrome (SIDS), as well as general nap time routines for all ages;
4. Correct food preparation and storage techniques, if employee prepares food;
5. Proper handling and storage of human milk when applicable and formula preparation if formula is handled;
6. Bottle preparation including guidelines for human milk and formula if care is provided to children with bottles;
7. Proper use of gloves in compliance with Occupational Safety and Health Administration (OSHA) bloodborne pathogens regulations;
8. Injury prevention and safety including the role of mandatory child abuse reporter to report any suspected abuse/neglect.
Emergency plans and practices;
Access to list of authorized individuals for releasing children.

RATIONALE: Upon employment, substitutes should be able to carry out the duties assigned to them. Because facilities and the children enrolled in them vary, orientation programs for new substitutes can be most productive. Because of frequent staff turnover, child care programs must institute orientation programs as needed that protect the health and safety of children and new staff (1-3).

Most SIDS deaths in child care occur on the first day of care or within the first week due to unaccustomed prone (on stomach) sleeping. Unaccustomed prone sleeping increases the risk of SIDS eighteen times (4).

COMMENTS: Anyone who substitutes regularly should be up to date on all basic training as specified in this standard.

TYPE OF FACILITY: Center; Large Family Child Care Home; Small Family Child Care Home

REFERENCES:

1. Gore, J. S. 1997. Does school-age child care staff training make a difference? School-Age Connections, vol. 6. http://www.canr
.uconn.edu/ces/child/newsarticles/SAC643.html.

2. Crosland, K. A., G. Dunlap, W. Sager, et al. 2008. The effects of staff training on the types of interactions observed at two group homes for foster care children. Research Soc Work 18:410-20.

3. Cain, D. W., L. C. Rudd, T. F. Saxon. 2007. Effects of professional development training on joint attention engagement in low-quality childcare centers. Early Child Devel Care 177:159-85.

4. Moon, R. Y., T. Calabrese, L. Aird. 2008. Reducing the risk of sudden infant death syndrome in child care and changing provider practices: Lessons learned from a demonstration project. Pediatrics 122:788-98.

1.6 Consultants

STANDARD 1.6.0.1: Child Care Health Consultants

A facility should identify and engage/partner with a child care health consultant (CCHC) who is a licensed health professional with education and experience in child and community health and child care and preferably specialized training in child care health consultation.

CCHCs have knowledge of resources and regulations and are comfortable linking health resources with child care facilities.

The child care health consultant should be knowledgable in the following areas:

Consultation skills both as a child care health consultant as well as a member of an interdisciplinary team of consultants;
National health and safety standards for out-of-home child care;
Indicators of quality early care and education;
Day-to-day operations of child care facilities;
State child care licensing and public health requirements;
State health laws, Federal and State education laws (e.g., ADA, IDEA), and state professional practice acts for licensed professionals (e.g., State Nurse Practice Acts);
Infancy and early childhood development, social and emotional health, and developmentally appropriate practice;
Recognition and reporting requirements for infectious diseases;
American Academy of Pediatrics (AAP) and Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) screening recommendations and immunizations schedules for children;
Importance of medical home and local and state resources to facilitate access to a medical home as well as child health insurance programs including Medicaid and State Children’s Health Insurance Program (SCHIP);
Injury prevention for children;
Oral health for children;
Nutrition and age-appropriate physical activity recommendations for children including feeding of infants and children, the importance of breastfeeding and the prevention of obesity;
Inclusion of children with special health care needs, and developmental disabilities in child care;
Safe medication administration practices;
Health education of children;
Recognition and reporting requirements for child abuse and neglect/child maltreatment;
Safe sleep practices and policies (including reducing the risk of SIDS);
Development and implementation of health and safety policies and practices including poison awareness and poison prevention;
Staff health, including adult health screening, occupational health risks, and immunizations;
Disaster planning resources and collaborations within child care community;
Community health and mental health resources for child, parent/guardian and staff health;
Importance of serving as a healthy role model for children and staff.

The child care health consultant should be able to perform or arrange for performance of the following activities:

Assessing caregivers’/teachers’ knowledge of health, development, and safety and offering training as indicated;
Assessing parents’/guardians’ health, development, and safety knowledge, and offering training as indicated;
Assessing children’s knowledge about health and safety and offering training as indicated;
Conducting a comprehensive indoor and outdoor health and safety assessment and on-going observations of the child care facility;
Consulting collaboratively on-site and/or by telephone or electronic media;
Providing community resources and referral for health, mental health and social needs, including accessing medical homes, children’s health insurance programs (e.g., CHIP), and services for special health care needs;
Developing or updating policies and procedures for child care facilities (see comment section below);
Reviewing health records of children;
Reviewing health records of caregivers/teachers;
Assisting caregivers/teachers and parents/guardians in the management of children with behavioral, social and emotional problems and those with special health care needs;
Consulting a child’s primary care provider about the child’s individualized health care plan and coordinating services in collaboration with parents/guardians, the primary care provider, and other health care professionals (the CCHC shows commitment to communicating with and helping coordinate the child’s care with the child’s medical home, and may assist with the coordination of skilled nursing care services at the child care facility);
Consulting with a child’s primary care provider about medications as needed, in collaboration with parents/guardians;
Teaching staff safe medication administration practices;
Monitoring safe medication administration practices;
Observing children’s behavior, development and health status and making recommendations if needed to staff and parents/guardians for further assessment by a child’s primary care provider;
Interpreting standards, regulations and accreditation requirements related to health and safety, as well as providing technical advice, separate and apart from an enforcement role of a regulation inspector or determining the status of the facility for recognition;
Understanding and observing confidentiality requirements;
Assisting in the development of disaster/emergency medical plans (especially for those children with special health care needs) in collaboration with community resources;
Developing an obesity prevention program in consultation with a nutritionist/registered dietitian (RD) and physical education specialist;
Working with other consultants such as nutritionists/RDs, kinesiologists (physical activity specialists), oral health consultants, social service workers, early childhood mental health consultants, and education consultants.

The role of the CCHC is to promote the health and development of children, families, and staff and to ensure a healthy and safe child care environment (11).

The CCHC is not acting as a primary care provider at the facility but offers critical services to the program and families by sharing health and developmental expertise, assessments of child, staff, and family health needs and community resources. The CCHC assists families in care coordination with the medical home and other health and developmental specialists. In addition, the CCHC should collaborate with an interdisciplinary team of early childhood consultants, such as, early childhood education, mental health, and nutrition consultants.

In order to provide effective consultation and support to programs, the CCHC should avoid conflict of interest related to other roles such as serving as a caregiver/teacher or regulator or a parent/guardian at the site to which child care health consultation is being provided.

The CCHC should have regular contact with the facility’s administrative authority, the staff, and the parents/guardians in the facility. The administrative authority should review, and collaborate with the CCHC in implementing recommended changes in policies and practices. In the case of consulting about children with special health care needs, the CCHC should have contact with the child’s medical home with permission from the child’s parent/guardian.

Programs with a significant number of non-English-speaking families should seek a CCHC who is culturally sensitive and knowledgeable about community health resources for the parents’/guardians’ native culture and languages.

RATIONALE: CCHCs provide consultation, training, information and referral, and technical assistance to caregivers/teachers (10). Growing evidence suggests that CCHCs support healthy and safe early care and education settings and protect and promote the healthy growth and development of children and their families (1-10). Setting health and safety policies in cooperation with the staff, parents/guardians, health professionals, and public health authorities will help ensure successful implementation of a quality program (3). The specific health and safety consultation needs for an individual facility depend on the characteristics of that facility (1-2). All facilities should have an overall child care health consultation plan (1,2,10).

The special circumstances of group care may not be part of the health care professional’s usual education. Therefore, caregivers/teachers should seek child care health consultants who have the necessary specialized training or experience (10). Such training is available from instructors who are graduates of the National Training Institute for Child Care Health Consultants (NTI) and in some states from state-level mentoring of seasoned child care health consultants known to chapter child care contacts networked through the Healthy Child Care America (HCCA) initiatives of the AAP.

Some professionals may not have the full range of knowledge and expertise to serve as a child care health consultant but can provide valuable, specialized expertise. For example, a sanitarian may provide consultation on hygiene and infectious disease control and a Certified Playground Safety Inspector would be able to provide consultation about gross motor play hazards.

COMMENTS: The U.S. Department of Health and Human Services Maternal and Child Health Bureau (MCHB) has supported the development of state systems of child care health consultants through HCCA and State Early Childhood Comprehensive Systems grants and continues to support the NTI. Child care health consultants provide services to centers as well as family child care homes through on-site visits as well as phone or email consultation. Approximately twenty states are funding child care health consultant initiatives through a variety of funding sources, including Child Care Development Block Grants, TANF, and Title V. In some states a wide variety of health consultants, e.g., nutrition, kinesiology (physical activity), mental health, oral health, environmental health, may be available to programs and those consultants may operate through a team approach. Connecticut is an example of one state that has developed interdisciplinary training for early care and education consultants (health, education, mental health, social service, nutrition, and special education) in order to develop a multidisciplinary approach to consultation (8).

Certificates are provided for graduates of the NTI upon completion of the course and continuing education units are awarded. Some states offer CCHC training. Not all states implement CCHC training as modeled by the NTI. Some states offer continuing education units, college credit, and/or certificate of completion. Credentialing is an umbrella term referring to the various means employed to designate that individuals or organizations have met or exceeded established standards. These may include accreditation of programs or organizations and certification, registration, or licensure of individuals. Accreditation refers to a legitimate state or national organization verifying that an educational program or organization meets standards. Certification is the process by which a non-governmental agency or association grants recognition to an individual who has met predetermined qualifications specified by the agency or association. Certification is applied for by individuals on a voluntary basis and represents a professional status when achieved. Typical qualifications include 1) graduation from an accredited or approved program and 2) acceptable performance on a qualifying examination. While there is no national accreditation of CCHC training programs or individual CCHCs at this time, this is a future goal. Contact NTI at nti@unc.edu for additional information.

CCHC services may be provided through the public health system, resource and referral agency, private source, local community action program, health professional organizations, other non-profit organizations, and/or universities. Some professional organizations include child care health consultants in their special interest groups, such as the AAP’s Section on Early Education and Child Care and the National Association of Pediatric Nurse Practitioners (NAPNAP).

CCHCs who are not employees of health, education, family service or child care agencies may be self-employed. Compensating them for their services via fee-for-service, an hourly rate, or a retainer fosters access and accountability.

Listed below is a sample of the policies and procedures child care health consultants should review and approve:

Admission and readmission after illness, including inclusion/exclusion criteria;
Health evaluation and observation procedures on intake, including physical assessment of the child and other criteria used to determine the appropriateness of a child’s attendance;
Plans for care and management of children with communicable diseases;
Plans for prevention, surveillance and management of illnesses, injuries, and behavioral and emotional problems that arise in the care of children;
Plans for caregiver/teacher training and for communication with parents/guardians and primary care providers;
Policies regarding nutrition, nutrition education, age-appropriate infant and child feeding, oral health, and physical activity requirements;
Plans for the inclusion of children with special health or mental health care needs as well as oversight of their care and needs;
Emergency/disaster plans;
Safety assessment of facility playground and indoor play equipment;
Policies regarding staff health and safety;
Policy for safe sleep practices and reducing the risk of SIDS;
Policies for preventing shaken baby syndrome/abusive head trauma;
Policies for administration of medication;
Policies for safely transporting children;
Policies on environmental health – handwashing, sanitizing, pest management, lead, etc.

TYPE OF FACILITY: Center; Large Family Child Care Home; Small Family Child Care Home

REFERENCES:

1. Alkon, A., J. Bernzweig, K. To, J. K. Mackie, M. Wolff, J. Elman. 2008. Child care health consultation programs in California: Models, services, and facilitators. Public Health Nurs 25:126-39.

2. Alkon, A., J. Farrer, J. Bernzweig. 2004. Roles and responsibilities of child care health consultants: Focus group findings. Pediatric Nurs 30:315-21.

3. Crowley, A. A. 2000. Child care health consultation: The Connecticut experience. Maternal Child Health J 4:67-75.

4. Gupta, R. S., S. Shuman, E. M. Taveras, M. Kulldorff, J. A. Finkelstein. 2005. Opportunities for health promotion education in child care. Pediatrics 116:499-505.

5. Farrer, J., A. Alkon, K. To. 2007. Child care health consultation programs: Barriers and opportunities. Maternal Child Health J 11:111-18.

6. Heath, J. M., et al. 2005. Creating a statewide system of multi-disciplinary consultation system for early care and education in Connecticut. Farmington, CT: Child Health and Development Institute of Connecticut. http://nitcci.nccic.acf.hhs.gov/resources/10262005_93815_901828.pdf.

7. Crowley, A. A., J. M Kulikowich. 2009. Impact of training on child care health consultant knowledge and practice. Pediatric Nurs 35:93-100.

8. Crowley, A. A., R. M. Sabatelli. 2008. Collaborative child care health consultation: A conceptual model. J for Specialists in Pediatric Nurs 13:74-88.

9. Dellert, J. C., D. Gasalberti, K. Sternas, P. Lucarelli, J. Hall. 2006. Outcomes of child care health consultation services for child care providers in New Jersey: A pilot study. Pediatric Nurs 32:530-37.

10. Alkon, A., J. Bernzweig, K. To, M. Wolff, J. F. Mackie. 2009. Child care health consultation improves health and safety policies and practices. Academic Pediatrics 9:366-70.

11. Crowley, A. A. 2001. Child care health consultation: An ecological model. J Society Pediat Nurs 6:170-81.

STANDARD 1.6.0.2: Frequency of Child Care Health Consultation Visits

The child care health consultant (CCHC) should visit each facility as needed to review and give advice on the facility’s health component (1). Early childhood programs that serve any child younger than three years of age should be visited more frequently than child care programs that serve children three to five years of age. In both cases the frequency of visits should meet the needs of the composite group of children and be based on the needs of the program for training, support, and monitoring of child health and safety needs, including (but not limited to) infectious disease, injury prevention, safe sleep, nutrition, oral health, physical activity and outdoor learning, emergency preparation, medication administration, and the care of children with special health care needs. Written documentation of CCHC visits should be maintained at the facility.

RATIONALE: Almost everything that goes on in a facility and almost everything about the facility itself affects the health of the children, families, and staff it serves (1). Because infants are developing rapidly, environmental situations can quickly create harm. Their rapid changes in behavior make regular and frequent visits by the CCHC extremely important (2-4). In facilities where health and safety problems are present, staff require additional training and support to care for special health care needs or a high turnover rate of staff may occur, more frequent visits by the child care health consultant should be arranged (2).

COMMENTS: State child care regulations display a wide range of frequency and recommendations in states that require CCHC visits, from as frequently as once a week for programs serving children under three years of age to twice a year for programs serving children three to five years of age (2,5,6).

TYPE OF FACILITY: Center; Large Family Child Care Home; Small Family Child Care Home

REFERENCES:

1. Alkon, A., J. Bernzweig, K. To, J. K. Mackie, M. Wolff, J. Elman. 2008. Child care health consultation programs in California: Models, services, and facilitators. Public Health Nurs 25:126-39.

2. Crowley, A. A. 2000. Child care health consultation: The Connecticut experience. Maternal Child Health J 4:67-75.

3. Dellert, J. C., D. Gasalberti, K. Sternas, P. Lucarelli, J. Hall. 2006. Outcomes of child care health consultation services for child care providers in New Jersey: A pilot study. Pediatric Nursing 32:530-37.

4. Gupta, R. S., S. Shuman, E. M. Taveras, M. Kulldorff, J. A. Finkelstein. 2005. Opportunities for health promotion education in child care. Pediatrics 116:499-505.

5. Healthy Child Care Consultant Network Support Center, CHT Resource Group. 2006. The influence of child care health consultants in promoting children’s health and well-being: A report on selected resources. http://hcccnsc.jsi.com/resources/publications/CC_lit_review_Screen_All.pdf.

6. National Resource Center for Health and Safety in Child Care and Early Education. 2010. Child care health consultant requirements and profiles by state. http://nrckids.org/RESOURCES/
cchc by state.pdf.

STANDARD 1.6.0.3: Early Childhood Mental Health Consultants

A facility should engage a qualified early childhood mental health consultant who will assist the program with a range of early childhood social-emotional and behavioral issues and who will visit the program at minimum quarterly and more often as needed.

The knowledge base of an early childhood mental health consultant should include:

Training, expertise and/or professional credentials in mental health (e.g., psychiatry, psychology, clinical social work, nursing, developmental-behavioral medicine, etc.);
Early childhood development (typical and atypical) of infants, toddlers, and preschool age children;
Early care and education settings and practices;
Consultation skills and approaches to working as a team with early childhood consultants from other disciplines, especially health and education consultants, to effectively support directors and caregivers/teachers.

The role of the early childhood mental health consultant should be focused on building staff capacity and be both proactive in decreasing the incidence of challenging classroom behaviors and reactive in formulating appropriate responses to challenging classroom behaviors and should include:

Developing and implementing classroom curricula regarding conflict resolution, emotional regulation, and social skills development;
Developing and implementing appropriate screening and referral mechanisms for behavioral and mental health needs;
Forming relationships with mental health providers and special education systems in the community;
Providing mental health services, resources and/or referral systems for families and staff;
Helping staff facilitate and maintain mentally healthy environments within the classroom and overall system;
Helping address mental health needs and reduce job stress within the staff;
Improving management of children with challenging behaviors;
Preventing the development of problem behaviors;
Providing a classroom climate that promotes positive social-emotional development;
Recognizing and appropriately responding to the needs of children with internalizing behaviors, such as persistent sadness, anxiety, and social withdrawal;
Actively teaching developmentally appropriate social skills, conflict resolution, and emotional regulation;
Addressing the mental health needs and daily stresses of those who care for young children, such as families and caregivers/teachers;
Helping the staff to address and handle unforeseen crises or bereavements that may threaten the mental health of staff or children and families, such as the death of a caregiver/teacher or the serious illness of a child.

RATIONALE: As increasing numbers of children are spending longer hours in child care settings, there is an increasing need to build the capacity of caregivers/teachers to attend to the social-emotional and behavioral well-being of children as well as their health and learning needs. Early childhood mental health underlies much of what constitutes school readiness, including emotional and behavioral regulation, social skills (i.e., taking turns, postponing gratification), the ability to inhibit aggressive or anti-social impulses, and the skills to verbally express emotions, such as frustration, anger, anxiety, and sadness. Supporting children’s health, mental health and learning requires a comprehensive approach. Child care programs need to have health, education, and mental health consultants who can help them implement universal, selected and targeted strategies to improve school readiness in young children in their care (1-5). Mental health consultants in collaboration with education and child care health consultants can reduce the risk for children being expelled, can reduce levels of problem behaviors, increase social skills and build staff efficacy and capacity (1-11).

COMMENTS: Access to an early childhood mental health consultant should be in the context of an ongoing relationship, with at least quarterly regular visits to the classroom to consult. However, even an on-call-only relationship is better than no relationship at all. Regardless of the frequency of contact, this relationship should be established before a crisis arises, so that the consultant can establish a useful proactive working relationship with the staff and be quickly mobilized when needs arise. This consultant should be viewed as an important part of the program’s support staff and should collaborate with all regular classroom staff, administration, and other consultants such as child care health consultants and education consultants, and support staff. In most cases, there is no single place in which to look for early childhood mental health consultants. Qualified potential consultants may be identified by contacting mental health and behavioral providers (e.g., child clinical and school psychologists, licensed clinical social workers, child psychiatrists, developmental pediatricians, etc.), as well as training programs at local colleges and universities where these professionals are being trained. Colleges and universities may be a good place to find well-supervised consultants-in-training at a potentially reasonable cost, although consultant turnover may be higher.

TYPE OF FACILITY: Center; Large Family Child Care Home; Small Family Child Care Home

REFERENCES:

1. Brennan, E. M., J. Bradley, M. D. Allen, D. F. Perry. 2008. The evidence base for mental health consultation in early childhood settings: A research synthesis addressing staff and program outcomes. Early Ed Devel 19:982-1022.

2. National Scientific Council on the Developing Child. 2008. Mental health problems in early childhood can impair learning and behavior for life. Working Paper no. 6. http://developingchild.harvard.edu/library/reports_and_working_papers/working_papers/wp6/.

3. Perry, D. F., M. D. Allen, E. M. Brennan, J. R. Bradley. 2010. The evidence base for mental health consultation in early childhood settings: A research synthesis addressing children’s behavioral outcomes. Early Ed Devel 21:795-824.

4. Perry, D. F., R. Kaufmann, J. Knitzer. 2007. Early childhood social and emotional health: Building bridges between services and systems. Baltimore, MD: Paul Brookes Publishing.

5. Perry, D. F., M. C. Dunne, L. McFadden, D. Campbell. 2008. Reducing the risk for preschool expulsion: Mental health consultation for young children with challenging behaviors. J Child Fam Studies 17:44-54.

6. Committee on Integrating the Science of Early Childhood Development, Board on Children, Youth, and Families. 2000. From neurons to neighborhoods. Ed. J. P. Shonkoff, D. A. Phillips. Washington, DC: National Academy Press.

7. Gilliam, W. S. 2005. Prekindergarteners left behind: Expulsion rates in state prekindergarten programs. Foundation for Child Development (FCD). Policy Brief Series no. 3. New York: FCD. http://www.challengingbehavior.org/explore/policy_docs/prek
_expulsion.pdf.

8. Gilliam, W. S., G. Shahar. 2006. Preschool and child care expulsion and suspension: Rates and predictors in one state. Infants Young Children 19:228-45.

9. Gilliam, W. S. 2007. Early Childhood Consultation Partnership: Results of a random-controlled evaluation. New Haven, CT: Yale Universty. http://www.chdi.org/admin/uploads/5468903394946c41768730.pdf.

10. American Academy of Pediatrics, Committee on School Health. 2003. Policy statement: Out-of-school suspension and expulsion. Pediatrics 112:1206-9.

11. Duran, F., K. Hepburn, M. Irvine, R. Kaufmann, B. Anthony, N. Horen, D. Perry. 2009. What works?: A study of effective early childhood mental health consultation programs. Washington, DC: Georgetown University Center for Child and Human Development. http://gucchdtacenter.georgetown.edu/publications/ECMHCStudy
_Report.pdf.

STANDARD 1.6.0.4: Early Childhood Education Consultants

A facility should engage an early childhood education consultant who will visit the program at minimum semi-annually and more often as needed. The consultant must have a minimum of a Baccalaureate degree and preferably a Master’s degree from an accredited institution in early childhood education, administration and supervision, and a minimum of three years in teaching and administration of an early care/education program. The facility should develop a written plan for this consultation which must be signed annually by the consultant. This plan should outline the responsibilities of the consultant and the services the consultant will provide to the program.

The knowledge base of an early childhood education consultant should include:

Working knowledge of theories of child development and learning for children from birth through eight years across domains, including socio-emotional development and family development;
Principles of health and wellness across the domains, including social and emotional wellness and approaches in the promotion of healthy development and resilience;
Current practices and materials available related to screening, assessment, curriculum, and measurement of child outcomes across the domains, including practices that aid in early identification and individualizing for a wide range of needs;
Resources that aid programs to support inclusion of children with diverse health and learning needs and families representing linguistic, cultural, and economic diversity of communities;
Methods of coaching, mentoring, and consulting that meet the unique learning styles of adults;
Familiarity with local, state, and national regulations, standards, and best practices related to early education and care;
Community resources and services to identify and serve families and children at risk, including those related to child abuse and neglect and parent education;
Consultation skills as well as approaches to working as a team with early childhood consultants from other disciplines, especially child care health consultants, to effectively support program directors and their staff.

The role of the early childhood education consultant should include:

Review of the curriculum and written policies, plans and procedures of the program;
Observations of the program and meetings with the director, caregivers/teachers, and parents/guardians;
Review of the professional needs of staff and program and provision of recommendations of current resources;
Reviewing and assisting directors in implementing and monitoring evidence based approaches to classroom management;
Maintaining confidences and following all Family Educational Rights and Privacy Act (FERPA) regulations regarding disclosures;
Keeping records of all meetings, consultations, recommendations and action plans and offering/providing summary reports to all parties involved;
Seeking and supporting a multidisciplinary approach to services for the program, children and families;
Following the National Association for the Education of Young Children (NAEYC) Code of Ethics;
Availability by telecommunication to advise regarding practices and problems;
Availability for on-site visit to consult to the program;
Familiarity with tools to evaluate program quality, such as the Early Childhood Environment Rating Scale–Revised (ECERS–R), Infant/Toddler Environment Rating Scale–Revised (ITERS–R), Family Child Care Environment Rating Scale–Revised (FCCERS–R), School-Age Care Environment Rating Scale (SACERS), Classroom Assessment Scoring System (CLASS), as well as tools used to support various curricular approaches.

RATIONALE: The early childhood education consultant provides an objective assessment of a program and essential knowledge about implementation of child development principles through curriculum which supports the social and emotional health and learning of infants, toddlers and preschool age children (1-5). Furthermore, utilization of an early childhood education consultant can reduce the need for mental health consultation when challenging behaviors are the result of developmentally inappropriate curriculum (6,7). Together with the child care health consultant, the early childhood education consultant offers core knowledge for addressing children’s healthy development.

TYPE OF FACILITY: Center; Large Family Child Care Home; Small Family Child Care Home

REFERENCES:

1. Dunn, L., K. Susan. 1997. What have we learned about developmentally appropriate practice? Young Children 52:4-13.

2. Wesley, P. W., V. Buysse. 2006. Ethics and evidence in consultation. Topics Early Childhood Special Ed 26:131-41.

3. Wesley, P. W., S. A. Palsha. 1998. Improving quality in early childhood environments through on-site consultation. Topics Early Childhood Special Ed 18:243-53.

4. Wesley, P. W., V. Buysee. 2005. Consultation in early childhood settings. Baltimore, MD: Brookes Publishing.

5. Bredekamp, S., C. Copple, eds. 2000. Developmentally appropriate practice in early childhood programs serving children from birth through age 8. Rev ed. National Association for the Education of Young Children (NAEYC). Publication no. 234. Washington, DC: NAEYC. http://www.naeyc.org/files/naeyc/file/positions/position statement Web.pdf.

6. The Connecticut Early Education Consultation Network. CEECN: Guidance, leadership, support. http://ctconsultationnetwork.org.

7. Connecticut Department of Public Health. Child day care licensing program. http://www.ct.gov/dph/cwp/view
.asp?a=3141&Q=387158&dphNav_GID=1823/.

STANDARD 1.6.0.5: Specialized Consultation for Facilities Serving Children with Disabilities

When children at the facility include those with special health care needs, developmental delay or disabilities, and mental health or behavior problems, the staff or documented consultants should involve any of the following consultants in the child’s care, with prior informed, written parental consent and as appropriate to each child’s needs:

A registered nurse, nurse practitioner with pediatric experience, or child care health consultant;
A physician with pediatric experience, especially those with developmental-behavioral training;
A registered dietitian;
A psychologist;
A psychiatrist;
A physical therapist;
An adaptive equipment technician;
An occupational therapist;
A speech pathologist;
An audiologist for hearing screenings conducted on-site at child care;
A vision screener;
A respiratory therapist;
A social worker;
A parent/guardian of a child with special health care needs;
Part C representative/service coordinator;
A mental health consultant;
Special learning consultant/teacher (e.g., teacher specializing in work with visually impaired child or sign language interpreters);
A teacher with special education expertise;
The caregiver/teacher;
Individuals identified by the parent/guardian;
Certified child passenger safety technician with training in safe transportation of children with special needs.

RATIONALE: The range of professionals needed may vary with the facility, but the listed professionals should be available as consultants when needed. These professionals need not be on staff at the facility, but may simply be available when needed through a variety of arrangements, including contracts, agreements, and affiliations. The parent’s participation and written consent in the native language of the parent, including Braille/sign language, is required to include outside consultants (1).

TYPE OF FACILITY: Center; Large Family Child Care Home; Small Family Child Care Home

REFERENCES:

1. Cohen, A. J. 2002. Liability exposure and child care health consultation. http://www.ucsfchildcarehealth.org/pdfs/forms/CCHCLiability.pdf.

1.7 Staff Health

STANDARD 1.7.0.1: Pre-Employment and Ongoing Adult Health Appraisals, Including Immunization

All paid and volunteer staff members should have a health appraisal before their first involvement in child care work. The appraisal should identify any accommodations required of the facility for the staff person to function in his or her assigned position.

Health appraisals for paid and volunteer staff members should include:

Physical exam;
Dental exam;
Vision and hearing screening;
The results and appropriate follow up of a tuberculosis (TB) screening, using the Tuberculin Skin Test (TST) or IGRA (interferon gamma release assay), once upon entering into the child care field with subsequent TB screening as determined by history of high risk for TB thereafter;
A review and certification of up-to-date immune status per the current Recommended Adult Immunization Schedule found in Appendix H, including annual influenza vaccination and up to date Tdap;
A review of occupational health concerns based on the performance of the essential functions of the job.

All adults who reside in a family child care home who are considered to be at high risk for TB, should have completed TB screening (1) as specified in Standard 7.3.10.1. Adults who are considered at high risk for TB include those who are foreign-born, have a history of homelessness, are HIV-infected, have contact with a prison population, or have contact with someone who has active TB.

Testing for TB of staff members with previously negative skin tests should not be repeated on a regular basis unless required by the local or state health department. A record of test results and appropriate follow-up evaluation should be on file in the facility.

RATIONALE: Caregivers/teachers need to be physically and emotionally healthy to perform the tasks of providing care to children. Performing their work while ill can spread infectious disease and illness to other staff and the children in their care (2). Under the Americans with Disabilities Act (ADA), employers are expected to make reasonable accommodations for persons with disabilities. Under ADA, accommodations are based on an individual case by case situation. Undue hardship is defined also on a case by case basis. Accommodation requires knowledge of conditions that must be accommodated to ensure competent function of staff and the well-being of children in care (3).

Since detection of tuberculosis using screening of healthy individuals has a low yield compared with screening of contacts of known cases of tuberculosis, public health authorities have determined that routine repeated screening of healthy individuals with previously negative skin tests is not a reasonable use of resources. Since local circumstances and risks of exposure may vary, this recommendation should be subject to modification by local or state health authorities.

COMMENTS: Child care facilities should provide the job description or list of activities that the staff person is expected to perform. Unless the job description defines the duties of the role specifically, under federal law the facility may be required to adjust the activities of that person. For example, child care facilities typically require the following activities of caregivers:

Moving quickly to supervise and assist young children;
Lifting children, equipment, and supplies;
Sitting on the floor and on child-sized furniture;
Washing hands frequently;
Responding quickly in case of an emergency;
Eating the same food as is served to the children (unless the staff member has dietary restrictions);
Hearing and seeing at a distance required for playground supervision or driving;
Being absent from work for illness no more often than the typical adult, to provide continuity of caregiving relationships for children in child care.

Healthy Young Children: A Manual for Programs, from the National Association for the Education of Young Children (NAEYC), provides a model form for an assessment by a health professional. See also Model Child Care Health Policies, from NAEYC and from the American Academy of Pediatrics (AAP).

Concern about the cost of health exams (particularly when many caregivers/teachers do not receive health benefits and earn minimum wage) is a barrier to meeting this standard. When staff members need hepatitis B immunization to meet Occupational Safety and Health Administration (OSHA) requirements (4), the cost of this immunization may or may not be covered under a managed care contract. If not, the cost of health supervision (such as immunizations, dental and health exams) must be covered as part of the employee’s preparation for work in the child care setting by the prospective employee or the employer. Child care workers are among those for whom annual influenza vaccination is strongly recommended.

Facilities should consult with ADA experts through the U.S. Department of Education funded Disability and Business Technical Assistance Centers (DBTAC) throughout the country. These centers can be reached by calling 1-800-949-4232 (callers are routed to the appropriate region) or by accessing regional center’s contacts directly at http://adata
.org/Static/Home.aspx.

TYPE OF FACILITY: Center; Large Family Child Care Home; Small Family Child Care Home

REFERENCES:

1. U.S. Department of Health and Human Services, Centers for Disease Control and Prevention. 2011. Recommended adult immunization schedule – United States, 2011. http://www.cdc.gov/vaccines/recs/schedules/.

2. Baldwin, D., S. Gaines, J. L. Wold, A. Williams. 2007. The health of female child care providers: Implications for quality of care. J Comm Health Nurs 24:1-7.

3. Keyes, C. R. 2008. Adults with disabilities in early childhood settings. Child Care Info Exchange 179:82-85.

4. Occupational Safety and Health Administration. 2008. Bloodborne pathogens. Title 29, pt. 1910.1030. http://www.osha
.gov/pls/oshaweb/owadisp.show_document?p_table=standards&p
_id=10051.

STANDARD 1.7.0.2: Daily Staff Health Check

On a daily basis, the administrator of the facility or caregiver/teacher should observe staff members, substitutes, and volunteers for obvious signs of ill health. When ill, staff members, substitutes and volunteers may be directed to go home. Staff members, substitutes, and volunteers should be responsible for reporting immediately to their supervisor any injuries or illnesses they experience at the facility or elsewhere, especially those that might affect their health or the health and safety of the children. It is the responsibility of the administration, not the staff member who is ill or injured, to arrange for a substitute caregiver/teacher.

RATIONALE: Sometimes adults report to work when feeling ill or become ill during the day but believe it is their responsibility to stay. The administrator’s or caregiver’s/teacher’s observation of illness followed by sending the staff member home may prevent the spread of illness. Arranging for a substitute caregiver/teacher ensures that the children receive competent care (1,2).

COMMENTS: Administrators and caregivers/teachers need guidelines to ensure proper application of this standard. For a demonstration of how to implement this standard, see the video series, Caring for Our Children, available from National Association for the Education of Young Children (NAEYC) and the American Academy of Pediatrics (AAP) (1).

TYPE OF FACILITY: Center; Large Family Child Care Home; Small Family Child Care Home

REFERENCES:

1. Baldwin D., S. Gaines, J. L. Wold, A. Williams. 2007. The health of female child care providers: Implications for quality of care. J Comm Health Nurs 24:1-7.

2. Murph, J. R., S. D. Palmer, D. Glassy, eds. 2005. Health in child care: A manual for health professionals. 4th ed. Elk Grove Village, IL: American Academy of Pediatrics.

STANDARD 1.7.0.3: Health Limitations of Staff

Staff and volunteers must have a primary care provider’s release to return to work in the following situations:

When they have experienced conditions that may affect their ability to do their job or require an accommodation to prevent illness or injury in child care work related to their conditions (such as pregnancy, specific injuries, or infectious diseases);
After serious or prolonged illness;
When their condition or health could affect promotion or reassignment to another role;
Before return from a job-related injury;
If there are workers’ compensation issues or if the facility is at risk of liability related to the employee’s or volunteer’s health problem.

If a staff member is found to be unable to perform the activities required for the job because of health limitations, the staff person’s duties should be limited or modified until the health condition resolves or employment is terminated because the facility can prove that it would be an undue hardship to accommodate the staff member with the disability.

RATIONALE: Under the Americans with Disabilities Act (ADA), employers are expected to make reasonable accommodations for persons with disabilities. Under ADA, accommodations are based on an individual case by case situation (1). Undue hardship is defined also on a case by case basis (1).

COMMENTS: Facilities should consult with ADA experts through the U.S. Department of Education funded Disability and Business Technical Assistance Centers throughout the country. These centers can be reached by calling 1-800-949-4232 and callers are routed to the appropriate region or accessing contacts directly at http://adata.org/Static/
Home.aspx.

TYPE OF FACILITY: Center; Large Family Child Care Home

REFERENCES:

1. ADA National Network. The Americans with Disabilities Act (ADA) from a civil rights perspective. http://adaanniversary.org/2010/ap03_ada_civilrights/03_ada_civilrights_09_natl.pdf.

STANDARD 1.7.0.4: Occupational Hazards

Written personnel policies of centers and large family child care homes should address the major occupational health hazards for workers in child care settings. Special health concerns of pregnant caregivers/teachers should be carefully evaluated, and up-to-date information regarding occupational hazards for pregnant caregivers/teachers should be made available to them and other workers. The occupational hazards including those regarding pregnant workers listed in Appendix B, Major Occupational Health Hazards, should be referenced and used in evaluations by caregivers/teachers and supervisors.

RATIONALE: Employees must be aware of the risks to which they are exposed so they can weigh those risks and take countermeasures (2). As a workforce composed primarily of women of childbearing age, pregnancy is common among caregivers/teachers in child care settings. In a study of child care personnel, one quarter of the study’s sample reported becoming pregnant since beginning work in child care, with higher pregnancy rates for directors (33%) and family home caregivers/teachers (36%) than for center staff (15%) (1).

TYPE OF FACILITY: Center; Large Family Child Care Home

REFERENCES:

1. The National Association of Family Child Care (NAFCC). 2005. Quality standards for NAFCC accreditation. 4th ed. Salt Lake City, UT: NAFCC. http://www.nafcc.org/documents/QualStd.pdf.

2. Aronson, S. S., T. R. Shope, eds. 2009. Managing infectious diseases in child care and schools: A quick reference guide. 2nd ed. Elk Grove Village, IL: American Academy of Pediatrics.

STANDARD 1.7.0.5: Stress

Caregivers/teachers should be able to:

Identify risks associated with stress;
Identify stressors specific to child caregiving;
Identify specific ways to manage stress in the child care environment.

The following measures to lessen stress for the staff should be implemented to the maximum extent possible:

Wages and benefits (including health care insurance) that fairly compensate the skills, knowledge, and performance required of caregivers/teachers, at the levels of wages and benefits paid for other jobs that require comparable skills, knowledge, and performance;
Job security;
Training to improve skills and hazard recognition;
Stress management and reduction training;
Written plan/policy in place for the situation in which a caregiver/teacher recognizes that s/he or a colleague is stressed and needs help immediately (the plan should allow for caregivers/teachers who feel they may lose control to have a short, but relatively immediate break away from the children at times of high stress);
Regular work breaks and paid time-off;
Appropriate child:staff ratios;
Liability insurance for caregivers/teachers;
Staff lounge separate from child care area with adult size furniture;
The use of sound-absorbing materials in the workspace;
Regular performance reviews which, in addition to addressing any areas requiring improvement, provide constructive feedback, individualized encouragement and appreciation for aspects of the job well performed;
Stated provisions for back-up staff, for example, to allow caregivers/teachers to take necessary time off when ill without compromising the function of the center or incurring personal negative consequences from the employer (this back-up should also include a stated plan to be implemented in the event a staff member needs to have a short, but relatively immediate break away from the children);
Adult size furniture in the classroom for the staff;
Access to experts in child development and behavior to help problem solve child specific issues.

RATIONALE: One of the best indicators of quality child care is consistent staff with low turnover rates (5,6).

According to the Bureau of Labor Statistics’ Website, “in 2007, hourly earnings of nonsupervisory workers in the child day care services industry averaged $10.53” (1). About 42% of all child care workers have a high school degree or less, reflecting the minimal training requirements for most jobs. Many child care workers leave the industry due to stressful working conditions and dissatisfaction with benefits and pay (1).

Stress reduction measures (particularly adequate wages and reasonable health care benefits) contribute to decreased staff turnover and thereby promote quality care (2). The health, welfare, and safety of adult workers in child care determine their ability to provide care for the children.

Serious physical abuse sometimes occurs when the caregiver/teacher is under high stress. Too much stress can not only affect the caregiver’s/teacher’s health, but also the quality of the care that the adult is able to give. A caregiver/teacher who is feeling too much stress may not be able to offer the praise, nurturing, and direction that children need for good development (3). Regular breaks with substitutes when the caregiver/teacher cannot continue to provide safe care can help ensure quality child care.

Sound-absorbing materials in the work area, break times, and a separate lounge allow for respite from noise and from non-auditory stress. Unwanted sound, or noise, can be damaging to hearing as well as to psychosocial well-being. The stress effects of noise will aggravate other stress factors present in the facility. Lack of adequate sound reduction measures in the facility can force the caregiver/teacher to speak at levels above those normally used for conversation, and thus may increase the risk of throat irritation. When caregivers/teachers raise their voices to be heard, the children tend to raise theirs, escalating the problem.

COMMENTS: Documentation of implementation of stress reduction measures should be on file in the facility.

Rest breaks of twenty minutes or less are customary in industry and are customarily paid for as working time. Meal periods (typically thirty minutes or more) generally need not be compensated as work time as long as the employee is completely relieved from duty for the entire meal period (4). For resources on respite or crisis care, contact the ARCH National Respite Network at http://archrespite.org.

Caregivers/teachers who use tobacco can experience stress related to nicotine withdrawals. For help dealing with stress from tobacco addiction, see the Tobacco Research and Intervention Program’s Forever Free booklet on smoking, stress, and mood at http://www.smokefree.gov/pubs/FFree6.pdf. Or, for help quitting smoking, visit the Smoke Free Website at http://www.smokefree.gov.

TYPE OF FACILITY: Center; Large Family Child Care Home; Small Family Child Care Home

REFERENCES:

1. U.S. Department of Labor, Bureau of Labor Statistics. 2010. Career guide to industries: Child day care services, 2010-11 Edition. http://www.bls.gov/oco/cg/cgs032.htm.

2. U.S. Department of Labor, Bureau of Labor Statistics. 2010. Occupational employment statistics: occupational employment and wages, May 2009. http://www.bls.gov/oes/current/oes399011.htm.

3. Healthy Childcare Consultants (HCCI). Stress management for child caregivers. Pelham, AL: HCCI.

4. U.S. Department of Labor, Wage and Hour Division. 2009. Fact sheet #46: Daycare centers and preschools under the Fair Labor Standards Act (FLSA). Rev. ed. http://www.dol.gov/whd/regs/compliance/whdfs46.pdf.

6. National Institute of Child Health and Human Development (NICHD). 2006. The NICHD study of early child care and youth development: Findings for children up to age 4 1/2 years. Rockville, MD: NICHD.

1.8 Human Resource Management

1.8.1 Benefits

STANDARD 1.8.1.1: Basic Benefits

The following basic benefits should be offered to staff:

Affordable health insurance;
Paid time-off (vacation, sick time, personal leave, holidays, family, parental and medical leave, etc.);
Social Security or other retirement plan;
Workers’ compensation;
Educational benefits.

Centers and large family child care homes should have written policies that detail these benefits of employees at the facility.

RATIONALE: The quality and continuity of the child care workforce is the main determining factor of the quality of care. Nurturing the nurturers is essential to prevent burnout and promote retention. Fair labor practices should apply to child care as well as other work settings. Child care workers should be considered as worthy of benefits as workers in other careers.

Medical coverage should include the cost of the health appraisals and immunizations required of child care workers, and care for the increased incidence of communicable disease and stress-related conditions in this work setting.

The potential for acquiring injuries and infections when caring for young children is a health and safety hazard for child care workers. Information abounds about the risk of infectious disease for children in child care settings. Children are reservoirs for many infectious agents. Staff members come into close and frequent contact with children and their excretions and secretions and are vulnerable to these illnesses. In addition, many child care workers are women who are planning a pregnancy or who are pregnant, and they may be vulnerable to potentially serious effects of infection on the outcome of pregnancy (2).

Sick leave is important to minimize the spread of communicable diseases and maintain the health of staff members. Sick leave promotes recovery from illness and thereby decreases the further spread or recurrence of illness.

Workplace benefits contribute to higher morale and less staff turnover, and thus promote quality child care. Lack of benefits is a major reason reported for high turnover of child care staff (1).

COMMENTS: Staff benefits may be appropriately addressed in center personnel policies and in state and federal labor standards. Not all the material that has to be addressed in these policies is appropriate for state child care licensing requirements. Having facilities acknowledge which benefits they do provide will help enhance the general awareness of staff benefits among child care workers and other concerned parties. Currently, this standard is difficult for many facilities to achieve, but new federal programs and shared access to small business benefit packages will help. Many options are available for providing leave benefits and education reimbursements, ranging from partial to full employer contribution, based on time employed with the facility.

Caregivers/teachers should be encouraged to have health insurance. Health benefits can include full coverage, partial coverage (at least 75% employer paid), or merely access to group rates. Some local or state child care associations offer reduced group rates for health insurance for child care facilities and individual caregivers/teachers.

TYPE OF FACILITY: Center; Large Family Child Care Home; Small Family Child Care Home

REFERENCES:

1. Whitebook, M., C. Howes, D. Phillips. 1998. Worthy work, unlivable wages: The National child care staffing study, 1988-1997. Washington, DC: Center for the Child Care Workforce.

2. National Association for the Education of Young Children (NAEYC). 2008. Leadership and management: A guide to the NAEYC early childhood program standards and related accreditation criteria. Washington, DC: NAEYC.

1.8.2 Evaluation

STANDARD 1.8.2.1: Staff Familiarity with Facility Policies, Plans and Procedures

All caregivers/teachers should be familiar with the provisions of the facility’s policies, plans, and procedures, as described in Chapter 9, Administration. The compliance with these policies, plans, and procedures should be used in staff performance evaluations and documented in the personnel file.

RATIONALE: Written policies, plans and procedures provide a means of staff orientation and evaluation essential to the operation of any organization (1).

TYPE OF FACILITY: Center; Large Family Child Care Home

REFERENCES:

1. Boone, L. E., D. L. Kurtz. 2010. Contemporary business. Hoboken, NJ: John Wiley and Sons.

STANDARD 1.8.2.2: Annual Staff Competency Evaluation

For each employee, there should be a written annual self-evaluation, a performance review from the personnel supervisor, and a continuing education/professional development plan based on the needs assessment, described in Standard 1.4.4.1 through Standard 1.4.5.4.

RATIONALE: A system for evaluation of employees is a basic component of any personnel policy (1). Staff members who are well trained are better able to prevent, recognize, and correct health and safety problems (2).

COMMENTS: Formal evaluation is not a substitute for continuing feedback on day-to-day performance. Performance appraisals should include a customer satisfaction component and/or a peer review component. Compliance with this standard may be determined by licensing requirements set by the state and local regulatory processes, and by state and local funding requirements, or by accrediting bodies (1). In some states, a central Child Development Personnel Registry may track and certify the qualifications of staff.

TYPE OF FACILITY: Center; Large Family Child Care Home

REFERENCES:

1. National Association for the Education of Young Children (NAEYC). 2008. Leadership and management: A guide to the NAEYC early childhood program standards and related accreditation criteria. Washington, DC: NAEYC.

2. Owens, C. 1997. Rights in the workplace: A guide for child care teachers. Washington, DC: Worker Option Resource Center.

STANDARD 1.8.2.3: Staff Improvement Plan

When a staff member of a center or a large family child care home does not meet the minimum competency level, that employee should work with the employer to develop a plan to assist the person in achieving the necessary skills. The plan should include a timeline for completion and consequences if it is not achieved.

RATIONALE: Children must be protected from incompetent caregiving. A system for evaluation and a plan to promote continued development are essential to assist staff to meet performance requirements (1).

COMMENTS: Whether the caregiver/teacher meets the minimum competency level is related to the director’s assessment of the caregiver’s/teacher’s performance.

TYPE OF FACILITY: Center; Large Family Child Care Home

REFERENCES:

1. University of California Berkeley Human Resources. Guide to managing human resources. Chapter 7: Performance management. http://hrweb.berkeley.edu/guides/managing-hr/managing
-successfully/performance-management/introduction/.

STANDARD 1.8.2.4: Observation of Staff

Observation of staff by a designee of the program director should include an assessment of each member’s adherence to the policies and procedures of the facility with respect to sanitation, hygiene, and management of infectious diseases. Routine, direct observation of employees is the best way to evaluate hygiene and safety practices. The observation should be followed by positive and constructive feedback to staff. Staff will be informed in their job description and/or employee handbook that observations will be made.

RATIONALE: Ongoing observation is an effective tool to evaluate consistency of staff adherence to program policies and procedures (1). It also serves to identify areas for additional orientation and training.

COMMENTS: Videotaping of these assessments may be a useful way to provide feedback to staff around their adherence to policies and procedures regarding hygiene and safety practices. If videotaping includes interactions with children, parent/guardian permission must be obtained before taping occurs. Desirable interactions can be encouraged and discussing methods of improvement can be facilitated through videotaping. Videotaped interactions can also prove useful to caregivers/teachers when informing, illustrating and discussing an issue with the parents/guardians. It gives the parents/guardians a chance to interpret the observations and begin a healthy, respectful dialogue with caregivers/teachers in developing a consistent approach to supporting their child’s healthy development. Sharing videotaping must have participant approval to avoid privacy issues.

If the staff follows the National Association for the Education of Young Children (NAEYC) Code of Ethical Conduct, peers are expected to observe, support and guide peers. In addition within the role of the child care health consultant and the education consultant are guidelines for observation of staff within the classroom. It should be within the role of the director and assistant director guidelines for direct observation of staff for health, safety, developmentally appropriate practice, and curriculum. For more information on the NAEYC Code of Ethical Conduct, go to http://www.naeyc.org/files/naeyc/file/positions/PSETH05.pdf.

TYPE OF FACILITY: Center; Large Family Child Care Home

REFERENCES:

1. Nolan, Jr., J. F., L. A. Hoover. 2010. Teacher supervision and evaluation. Hoboken, NJ: John Wiley and Sons.

STANDARD 1.8.2.5: Handling Complaints About Caregivers/Teachers

When complaints are made to licensing or referral agencies about caregivers/teachers, the caregivers/teachers should receive formal notice of the complaint and the resulting action, if any. Caregivers/teachers should maintain records of such complaints, post substantiated complaints with correction action, make them available to parents/guardians on request, and post a notice of how to contact the state agency responsible for maintaining complaint records.

RATIONALE: Parents/guardians seeking child care should know if previous complaints have been made, particularly if the complaint is substantiated. This information should be easily accessible to the parents/guardians. Parents/guardians can then evaluate whether or not the complaint is valid, and whether the complaint has been adequately addressed and necessary changes have been made.

COMMENTS: This policy requires program development by licensing agencies.

TYPE OF FACILITY: Center; Large Family Child Care Home; Small Family Child Care Home